PATIENT HEALTH QUESTIONNAIRE 9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer) 0 — Not at all 1 — Several days 2 — More than half the days 3 — Nearly every day 1. Little interest or pleasure indoing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or havinglittle energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 FOR OFFICE CODING _+_+_+_ = Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. ———————————————————————————————————————————————————————————————————————————————————— Generalized Anxiety Disorder 7-item (GAD-7) scale Date: _______________ Name: _____________________________________ DOB: _______________ Over the last 2 weeks, how often have you been bothered by the following problems? 0 — Not at all 1 — Several days 2 — More than half the days 3 — Nearly every day 1. Feeling nervous, anxious, or on edge 0 1 2 3 2. Not being able to stop or control worrying 0 1 2 3 3. Worrying too much about different things 0 1 2 3 4. Trouble relaxing 0 1 2 3 5. Being so restless that it's hard to sit still 0 1 2 3 6. Becoming easily annoyed or irritable 0 1 2 3 7. Feeling afraid as if something awful might happen 0 1 2 3 Add the score for each column _+_+_+_ Total Score (add your column scores) = If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097. ———————————————————————————————————————————————————————————————————————————————————— PACKAGE LEAFLET: INFORMATION FOR THE USER Sertraline 50 mg Film coated Tablets Sertraline 100 mg Film coated Tablets (Sertraline) Read all of this leaflet carefully before you start taking this medicine because it contains important information for you. • Keep this leaflet. You may need to read it again. • If you have any further questions, ask your doctor or pharmacist. • This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours. • If any of the side effects gets talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. See section 4. What is in this leaflet: 1. What Sertraline Tablets is and what it is used for. 2. What you need to know before you take Sertraline Tablets. 3. How to take Sertraline Tablets. 4. Possible side effects. 5. How to store Sertraline Tablets. 6. Contents of the pack and other information. 1. What Sertraline Tablets is and what it is used for Sertraline Tablets contains the active substance sertraline and are used to treat depression and/or anxiety disorders. Sertraline belongs to a group of antidepressant drugs called Selective Serotonin Re-uptake inhibitors. Sertraline Tablets can be used to treat: • Depression and prevention of recurrence of depression (in adults). • Social anxiety disorder (in adults). • Post traumatic stress disorder (PTSD) (in adults). • Panic disorder (in adults). • Obsessive compulsive disorder (OCD) (in adults and children and adolescents aged 6-17 years old). Depression is a clinical illness with symptoms like feeling sad, unable to sleep properly or to enjoy life as you used to. OCD and Panic disorders are illnesses linked to anxiety with symptoms like being constantly troubled by persistent ideas (obsessions) that make you carry out repetitive rituals (compulsions). PTSD is a condition that can occur after a very emotionally traumatic experience, and has some symptoms that are similar to depression and anxiety. Social anxiety disorder (social phobia) is an illness linked to anxiety. It is characterised by feelings of intense anxiety or distress in social situations (for example: talking to strangers, speaking in front of groups of people, eating or drinking in front of others or worrying that you might behave in an embarrassing manner). Your doctor has decided that this medicine is suitable for treating your illness. You should ask your doctor if you are unsure why you have been given Sertraline Tablets. 2. What you need to know before you take Sertraline Tablets Do not take Sertraline Tablets: • If you are allergic (hypersensitive) to sertraline or any of the other ingredients of this medicine (listed in section 6). • If you are taking or have taken medicines called monoamine oxidase inhibitors (MAOIs such as selegiline, moclobemide) or MAOI like drugs (such as linezolid). If you stop treatment with sertraline, you must wait until at least one week before you start treatment with a MAOI. After stopping treatment with a MAOI, you must wait at least 2 weeks before you can start treatment with sertraline. • If you are taking another medicine called Pimozide (a medicine for mental disorders such as psychosis). Warnings and precautions Talk to your doctor or pharmacist before taking Sertraline Tablets. Medicines are not always suitable for everyone. Tell your doctor before you take Sertraline Tablets, if you suffer from or have suffered in the past from any of the following conditions: • If you have epilepsy (fit) or a history of seizures. If you have a fit (seizure), contact your doctor immediately. • If you have suffered from manic depressive illness (bipolar disorder) or schizophrenia. If you have a manic episode, contact your doctor immediately. • If you have or have previously had thoughts of harming or killing yourself (see below-Thoughts of suicide and worsening of your depression or anxiety disorder). • If you have Serotonin Syndrome. In rare cases this syndrome may occur when you are taking certain medicines at the same time as sertraline. (For symptoms, see section 4. Possible Side Effects). Your doctor will have told you whether you have suffered from this in the past. • If you have low sodium level in your blood, since this can occur as a result of treatment with Sertraline Tablets. You should also tell your doctor if you are taking certain medicines for hypertension, since these medicines may also alter the sodium level in your blood. • If you are elderly as you may be more at risk of having low sodium level in your blood (see above). • If you have liver disease; your doctor may decide that you should have a lower dose of Sertraline Tablets. • If you have diabetes; your blood glucose levels may be altered due to Sertraline Tablets and your diabetes medicines may need to be adjusted. • If you have suffered from bleeding disorders or have been taking medicines which thin the blood (e.g. acetylsalicylic acid (aspirin), or warfarin) or may increase the risk of bleeding, or if you are pregnant (see Pregnancy, breast-feeding and fertility). • If you are a child or adolescent under 18 years old. Sertraline Tablets should only be used to treat children and adolescents aged 6-17 years old, suffering from obsessive compulsive disorder (OCD). If you are being treated for this disorder, your doctor will want to monitor you closely (see below Children and adolescents). • If you are having electro-convulsive therapy (ECT). • If you have eye problems, such as certain kinds of glaucoma (increased pressure in the eye) • If you have been told that you have an abnormality of your heart tracing after an electrocardiogram (ECG) known as prolonged QT interval. • If you have heart disease, low potassium levels or low magnesium levels, family history of QT prolongation, low heart rate and concomitant use of medications which prolong QT interval. • Medicines like sertraline tablets (so called SSRIs/SNRIs) may cause symptoms of sexual dysfunction (see section 4). In some cases, these symptoms have continued after stopping treatment. • The use of Buprenorphine/opioids together with sertraline can lead to serotonin syndrome, a potentially life-threatening condition (see “Other medicines and Sertraline Tablets”). Restlessness/Akathisia: The use of sertraline has been linked to a distressing restlessness and need to move, often being unable to sit or stand still (akathisia). This is most likely to occur during the first few weeks of treatment. Increasing the dose may be harmful so if you develop such symptoms you should talk to your doctor. Withdrawal reactions: Side effects relating to stopping treatment (withdrawal reactions) are common, particularly if the treatment is stopped suddenly (see section 3 If you stop taking Sertraline Tablets and section 4 Possible side effects). The risk of withdrawal symptoms depends on the length of treatment, dosage, and the rate at which the dose is reduced. Generally, such symptoms are mild to moderate. However, they can be serious in some patients. They normally occur within the first few days after stopping treatment. In general, such symptoms disappear on their own and wear off within 2 weeks. In some patients they may last longer (2-3 months or more). When stopping treatment with sertraline it is recommended to reduce the dose gradually over a period of several weeks or months, and you should always discuss the best way of stopping treatment with your doctor. Thoughts of suicide and worsening of your depression or anxiety disorder: If you are depressed and/or have anxiety disorders you can sometimes have thoughts of harming or killing yourself. These may be increased when first starting antidepressants, since these medicines all take time to work, usually about two weeks but sometimes longer. You may be more likely to think like this: • If you have previously had thoughts about killing or harming yourself. • If you are a young adult. Information from clinical trials has shown an increased risk of suicidal behaviour in adults aged less than 25 years with psychiatric conditions who were treated with an antidepressant. If you have thoughts of harming or killing yourself at any time, contact your doctor or go to a hospital straight away. You may find it helpful to tell a relative or close friend that you are depressed or have an anxiety disorder, and ask them to read this leaflet. You might ask them to tell you if they think your depression or anxiety is getting worse, or if they are worried about changes in your behaviour. Children and adolescents: Sertraline should not usually be used in children and adolescents less than 18 years old, except for patients with Obsessive Compulsive Disorder (OCD). Patients under 18 have an increased risk of undesirable effects, such as suicide attempt, thoughts of harming or killing themselves (suicidal thoughts) and hostility (mainly aggressiveness, oppositional behaviour and anger) when they are treated with this class of medicines. Nevertheless, it is possible that your doctor decides to prescribe Sertraline Tablets to a patient under 18 if it is in the patient's interest. If your doctor has prescribed Sertraline Tablets to you and you are less than 18 years old and you want to discuss this, please contact him/her. Furthermore, if any of the symptoms listed above appear or worsen while you are taking Sertraline Tablets, you should inform your doctor. Also, the long-term safety of Sertraline Tablets in regard to growth, maturation and learning (cognitive) and behavioural development in this age group has not yet been demonstrated. Other medicines and Sertraline tablets: Tell your doctor or pharmacist if you are taking, have recently take any other medicines. Some medicines can affect the way Sertraline Tablets works, or Sertraline Tablets itself can reduce the effectiveness of other medicines taken at the same time. Taking Sertraline Tablets together with the following medicines may cause serious side effects: • Medicines called monoamine oxidase inhibitors (MAOIs), like moclobemide (to treat depression) and selegiline (to treat Parkinson’s disease) and the antibiotic linezolid. Do not use Sertraline Tablets together with these medicines. • Medicines to treat mental disorders such as psychosis (pimozide). Do not use Sertraline Tablets together with pimozide. • Buprenorphine / opioids (used to treat opioid overdose). These medicines may interact with Sertraline Tablets and you may experience symptoms such as involuntary, rhythmic contractions of muscles, including the muscles that control movement of the eye, agitation, hallucinations, coma, excessive sweating, tremor, exaggeration of reflexes, increased muscle tension, body temperature above 38£C. Contact your doctor when experiencing such symptoms. Talk to your doctor if you are taking the following medicine: • Medicines containing amphetamines (used to treat attention deficit hyperactivity disorder (ADHD), narcolepsy, and obesity). • Herbal medicine containing St. John’s Wort (Hypericum perforatum). The effects of St. John’s Wort may last for 1-2 weeks. • Products containing the amino acid tryptophan. • Medicines to treat severe pain (e.g. tramadol). • Medicine used to treat pain and fever (metamizole) • Medicines to treat opiod dependence (e.g. buprenorphine) • Medicines used in anaesthesia or to treat chronic pain (fentanyl, mivacurium and suxamethonium). • Medicines to treat migraines (e.g. sumatriptan). • Blood thinning medicine (warfarin). • Medicines to treat pain/arthritis (Non steroidal anti-inflammatory drug (NSAID) such as ibuprofen, acetylsalicylic acid (aspirin). • Sedatives (diazepam). • Diuretics (also called ‘water’ tablets). • Medicines to treat epilepsy (phenytoin, phenobarbital, carbamazepine). • Medicines to treat diabetes (tolbutamide). • Medicines to treat excessive stomach acid, ulcers and heartburn (cimetidine, omeprazole, lansoprazole, pantoprazole, rabeprazole). • Medicines to treat mania and depression (lithium). • Other medicines to treat depression (such as amitriptyline, nortriptyline, nefazodone, fluoxetine, fluvoxamine). • Medicines to treat schizophrenia and other mental disorders (such as perphenazine, levomepromazine and olanzapine). • Medicines used to treat high blood pressure, chest pain or regulate the rate and rhythm of the heart (such as verapamil, diltiazem, flecainide, propafenone). • Medicines used to treat bacterial infections (such as rifampicin, clarithromycin, telithromycin, erythromycin). • Medicines used to treat fungal infections (such as ketoconazole, itraconazole, posaconazole, voriconazole, fluconazole). • Medicines used to treat HIV/AIDS and Hepatitis C (protease inhibitors such as ritonavir, telaprevir). • Medicines used to prevent nausea and vomiting after an operation or chemotherapy (aprepitant). • Medicines known to increase the risk of changes in the electrical activity of the heart (e.g. some antipsychotics and antibiotics). Tests If you need to carry out any urine tests tell your doctor that you are taking Sertraline Tablets, as these tablets may interfere with the results. Sertraline Tablets with food, drink and alcohol: Sertraline tablets can be taken with or without food. Alcohol should be avoided whilst taking Sertraline Tablets. Sertraline should not be taken in combination with grapefruit juice, as this may increase the level of sertraline in your body. Pregnancy, breast-feeding and fertility: If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor or pharmacist for advice before taking this medicine. The safety of sertraline has not fully been established in pregnant women. Sertraline will only be given to you when pregnant if your doctor considers that the benefit for you is greater than any possible risk to the developing baby. Make sure your midwife and/or doctor know you are on Sertraline Tablets. When taken during pregnancy, particularly in the last 3 months of pregnancy, medicines like Sertraline Tablets may increase the risk of a serious condition in babies, called persistent pulmonary hypertension of the new born (PPHN), making the baby breathe faster and appear bluish. These symptoms usually begin during the first 24 hours after the baby is born. If this happens to your baby, you should contact your midwife and/or doctor immediately. If you take Sertraline Tablets near the end of your pregnancy there may be an increased risk of heavy vaginal bleeding shortly after birth, especially if you have a history of bleeding disorders. Your doctor or midwife should be aware that you are taking Sertraline Tablets so they can advise you. Your new born baby might also have other conditions, which usually begin during the first 24 hours after birth. Symptoms include: • trouble with breathing, • a bluish skin or being too hot or cold, • blue lips, • vomiting or not feeding properly, • being very tired, not able to sleep or crying a lot, • stiff or floppy muscles, • tremors, jitters or fits, • increased reflex reactions, • irritability, • low blood sugar. If your baby has any of these symptoms when it is born, or you are concerned about your baby’s health, contact your doctor or midwife who will be able to advise you. There is evidence that sertraline passes into human breast milk. Sertraline should only be used in women during breast-feeding, if your doctor considers that the benefit exceeds any possible risk to the baby. Some medicines like sertraline may reduce the quality of sperm in animal studies. Theoretically, this could affect fertility, but impact on human fertility has not been observed as yet. Driving and using machines: Psychotropic drugs such as sertraline may influence your ability to drive or use machines. You should therefore not drive or operate machinery, until you know how this medication affects your ability to perform these activities. 3. How to take Sertraline Tablets Always take this medicine exactly as your doctor has told you. Check with your doctor or pharmacist if you are not sure. The recommended dose is: Adults: Depression and Obsessive Compulsive Disorder For depression and OCD, the usual effective dose is 50 mg/day. The daily dose may be increased in 50 mg increments and at intervals of at least one week over a period of weeks. The maximum recommended dose is 200 mg/day. Panic disorder, Social anxiety disorder and Post Traumatic Stress Disorder: For panic disorder, social anxiety disorder and post-traumatic stress disorder, treatment should be started at 25 mg/day, and increased to 50 mg/day after one week. The daily dose then may be increased in 50 mg increments over a period of weeks. The maximum recommended dose is 200 mg/day. Use in children and adolescents: Sertraline Tablets must only be used to treat children and adolescents suffering from OCD aged 6-17 years old. Obsessive Compulsive Disorder: Children aged 6 to 12: the recommended starting dose is 25 mg daily. After one week, your doctor may increase this to 50 mg daily. The maximum dose is 200 mg daily. Adolescents aged 13 to 17: the recommended starting dose is 50 mg daily. The maximum dose is 200 mg daily. If you have liver or kidney problems, please tell your doctor and follow the doctor’s instructions. Method of administration: Sertraline tablets may be taken with or without food. Take your medication once daily either in the morning or evening. Your doctor will advise you on how long to take this medication for. This will depend on the nature of your illness and how well you are responding to the treatment. It may take several weeks before your symptoms begin to improve. Treatment of depression should usually continue for 6 months after improvement. If you take more Sertraline Tablets than you should: If you accidentally take too much Sertraline Tablets, contact your doctor at once or go to the nearest hospital casualty department. Always take the labelled medicine package with you, whether there is any medication left or not. Symptoms of overdose may include drowsiness, nausea and vomiting, rapid heart rate, shaking, agitation, dizziness and in rare cases unconsciousness. If you forget to take Sertraline Tablets: Do not take a double dose to make up for a forgotten dose. If you forget to take a dose, do not take the missed dose. Just take the next dose at the right time. If you stop taking Sertraline Tablets: Do not stop taking Sertraline Tablets unless your doctor tells you to. Your doctor will want to gradually reduce your dose of Sertraline Tablets over several weeks, before you finally stop taking this medicine. If you suddenly stop taking this medicine you may experience side effects such as dizziness, numbness, sleep disturbances, agitation or anxiety, headaches, feeling sick, being sick and shaking. If you experience any of these side effects, or any other side effects whilst stopping taking Sertraline Tablets, please speak to your doctor. If you have any further questions on the use of this product, ask your doctor or pharmacist. 4. Possible side effects Like all medicines, Sertraline Tablets can cause side effects, although not everybody gets them. Nausea is the most common side effect. The side effects depend on the dose and often disappear or lessen with continued treatment. Tell your doctor immediately: If you experience any of the following symptoms after taking this medicine, these symptoms can be serious. • Heart attack • Light-headedness, fainting, or chest discomfort which could be signs of changes in the electrical activity (seen on electrocardiogram) or abnormal rhythm of the heart. • If you have inflammation of the pancreas causing severe upper stomach pain often with feeling or being sick • A condition in which skeletal muscle is broken down, releasing muscle enzymes and electrolytes from inside the muscle cells (Rhabdomyolysis). • If you have decrease in white blood cells, which help fight infections (you may notice more infections e.g. sore throat, mouth ulcers and fever). • Decrease in clotting cells (you may bruise or bleed more easily) • If you develop a severe skin rash that causes blistering (erythema multiforme), (this can affect the mouth and tongue). These may be signs of a condition known as Stevens Johnson Syndrome, or Toxic Epidermal Necrolysis (TEN). Your doctor will stop your treatment in these cases. • Allergic reaction or allergy, which may include symptoms such as an itchy skin rash, breathing problems, wheezing, swollen eyelids, face or lips. • If you develop yellow skin and eyes which may mean liver damage. • Cases of suicidal ideation and suicidal behaviours have been reported during sertraline therapy or early after treatment discontinuation (see section 2.). • If you experience agitation, confusion, diarrhoea, high temperature and blood pressure, excessive sweating and rapid heartbeat. These are symptoms of Serotonin Syndrome. In rare cases this syndrome may occur when you are taking certain medicines at the same time as sertraline. Your doctor may wish to stop your treatment. • If you start to get feelings of restlessness and are not able to sit or stand still after you start to take Sertraline Tablets. You should tell your doctor if you start to feel restless. • If you have a fit (seizure). • If you have a manic episode (see section 2 “Warnings and precautions”). The following side effects were seen in clinical trials in adults. Very common (may affect more than 1 in 10 people): • insomnia, dizziness, sleepiness, headache, diarrhoea, feeling sick, dry mouth, ejaculation failure, fatigue. Common (may affect up to 1 in 10 people): • chest cold, Sore throat, runny nose, decreased appetite, increased appetite, • depression, feeling strange, nightmare, anxiety, agitation, nervousness, decreased sexual interest, teeth grinding, • shaking, muscular movement problems (such as moving a lot, tense muscles, difficulty walking and stiffness, spasms and involuntary movements of muscles)*, numbness and tingling, abnormal taste, lack of attention, • visual disturbance, ringing in ears, • palpitations, hot flush, yawning, • abdominal pain, vomiting, constipation, upset stomach, gas, • rash, increased sweating, muscle pain, erectile dysfunction, chest pain. • back pain, joint pain • menstrual irregularities, malaise • weakness, fever, weight increased, injury. Uncommon (may affect up to 1 in 100 people): • gastroenteritis, ear infection • tumour, • hypersentivity, seasonal allergy, • low thyroid hormones, • psychotic disorder, thinking abnormal, lack of caring, hallucination, aggression, feeling too happy, paranoia, • involuntary muscle contractions, abnormal coordination, moving a lot, amnesia, decreased feeling, speech disorder, dizziness while standing up, passing out, migraine, • enlarged pupils, • ear pain, fast heartbeat, heart problem, bleeding problems (such as stomach bleeding)*, high blood pressure, flushing, blood in urine • nose bleed, • tarry stools, tooth disorder, inflammation of the oesophagus, tongue problem, difficulty swallowing, haemorrhoids, increased saliva, tongue disorder, burping, • eye swelling, purple spots on skin, face oedema, hair loss, cold sweat, dry skin, hives, itching, • osteoarthritis, muscular weakness, muscle cramps*, muscle twitching, • night-time urination, unable to urinate, increase in urination, increase in frequency of urination, problem urinating, urinary incontinence, • vaginal haemorrhage, sexual dysfunction, female sexual dysfunction, chills, weakness, thirst, increased in liver enzyme levels, weight decreased. Rare (may affect up to 1 in 1,000 people): • diverticulitis, swollen lymph glands, decrease in clotting cells*, decrease in white blood cells*, • high cholesterol, low blood sugar, increase in blood sugar levels, low blood salt* • physical symptoms due to stress or emotions, drug dependence, sleep walking, premature ejaculation, • endocrine problems*, • coma, abnormal movements, difficulty moving, increased sensation, sensory disturbance, sudden severe headache (which may be a sign of a serious condition known as Reversible Cerebral Vasoconstriction Syndrome (RCVS))*, • gradually progressive visual field loss (glaucoma), tear problem, spots in front of eyes, double vision, light hurts eye, blood in the eye, problems controlling blood sugar levels (diabetes), • slow heartbeat, poor circulation of arms and legs, closing up of throat, breathing fast, breathing slow, difficulty talking, hiccups, • blood in stool, sore mouth, tongue ulceration, mouth ulceration, problems with liver function, • skin problem with blisters, hair rash, hair texture abnormal, skin odour abnormal, bone disorder, • decreased urination, urinary hesitation • dry vaginal area, red painful penis and foreskin, genital discharge, prolonged erection, breast discharge, • hernia, drug tolerance decreased, semen abnormal, problems with clotting, increase in blood cholesterol levels, relaxation of blood vessels procedure, unequal sized pupils, abnormal laboratory tests, breast enlargement, skin reaction to sun, vision abnormal and progressive scarring of the lung tissue (interstitial Lung Disease). • terrifying abnormal dreams • spots in front of eyes, glaucoma, double vision, light hurts eye, blood in the eye, unequal sized pupils, vision abnormal, tear problem Not Known: frequency cannot be estimated from the available data: • lockjaw*, • bedwetting*. • partial loss of vision • inflammation of the colon (causing diarrhoea) • heavy vaginal bleeding shortly after birth (postpartum haemorrhage), see Pregnancy in section 2 for more information * Side effect reported after marketing. Additional side effects in children and adolescents In clinical trials with children and adolescents, the side effects were generally similar to adults (see above). The most common side effects in children and adolescents were headache, insomnia, diarrhoea and feeling sick. Symptoms that can occur when treatment is discontinued If you suddenly stop taking this medicine you may experience side effects such as dizziness, numbness, sleep disturbances, agitation or anxiety, headaches, feeling sick, being sick and shaking (see section 3. “If you stop taking Sertraline Tablets”). An increased risk of bone fractures has been observed in patients taking this type of medicines. Reporting of side effects If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. By reporting side effects you can help provide more information on the safety of this medicine. 5. How to store Sertraline Tablets • Keep this medicine out of the sight and reach of children. • Do not use Sertraline Tablets after the expiry date, which is stated on the blister after EXP and on the carton after Expiry Date. The expiry date refers to the last day of that month. • This medicinal product does not require any special storage conditions. • Store in the original package. • Do not use Sertraline Tablets if you notice visible signs of deterioration. • Do not throw any medicines via wastewater or household waste. Ask your pharmacist hoe to throw away medicines you no longer use. These measures will help to protect the environment. 6. Contents of the pack and other information What Sertraline Tablet contains: The active substance is Sertraline. Sertraline 50 mg Film-coated Tablets: Each film-coated tablet contains 50 mg sertraline (as sertraline hydrochloride). Sertraline 100 mg Film-coated Tablets: Each film-coated tablet contains 100 mg sertraline (as sertraline hydrochloride) The other ingredients are: Core: Cellulose microcrystalline, Sodium starch glycolate (Type A), Hydroxypropylcellulose, Calcium hydrogen phosphate dihydrate, Magnesium stearate. Coating: Hypromellose, Macrogol 400, Polysorbate 80 and Titanium dioxide (E171). What Sertraline Tablets look like and contents of the pack: Sertraline 50 mg Film-coated tablets: White coloured, biconvex, capsule shaped, film coated tablets debossed with “I” and “C” on either side of scoreline on one side and plain on other side. The score line is only to facilitate breaking for ease of swallowing and not to divide into equal doses. Sertraline 100 mg Film-coated tablets: White coloured, biconvex, capsule shaped, film coated tablets debossed with “IJ” on one side and plain on other side. Sertraline tablets are packed in white opaque PVC – Aluminium blister packs & HDPE bottle pack. Pack sizes: Blister Pack: 10, 14, 28, 30, 42, 50, 56, 84 and 100 tablets. HDPE bottle pack: 50mg – 250’s, 100 mg – 250’s & 500’s (for hospital use only) Not all pack sizes may be marketed. Marketing Authorisation Holder: Accord Healthcare Limited, Sage House, 319 Pinner Road, North Harrow, Middlesex, HA1 4HF, United Kingdom. Manufacturer: Accord Healthcare Limited, Sage House, 319 Pinner Road, North Harrow, Middlesex, HA1 4HF, United Kingdom. This leaflet was last revised in July 2021. ———————————————————————————————————————————————————————————————————————————————————— PATIENT HEALTH QUESTIONNAIRE 9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer) 0 — Not at all 1 — Several days 2 — More than half the days 3 — Nearly every day 1. Little interest or pleasure indoing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or havinglittle energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 FOR OFFICE CODING _+_+_+_ = Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. ———————————————————————————————————————————————————————————————————————————————————— Generalized Anxiety Disorder 7-item (GAD-7) scale Date: _______________ Name: _____________________________________ DOB: _______________ Over the last 2 weeks, how often have you been bothered by the following problems? 0 — Not at all 1 — Several days 2 — More than half the days 3 — Nearly every day 1. Feeling nervous, anxious, or on edge 0 1 2 3 2. Not being able to stop or control worrying 0 1 2 3 3. Worrying too much about different things 0 1 2 3 4. Trouble relaxing 0 1 2 3 5. Being so restless that it's hard to sit still 0 1 2 3 6. Becoming easily annoyed or irritable 0 1 2 3 7. Feeling afraid as if something awful might happen 0 1 2 3 Add the score for each column _+_+_+_ Total Score (add your column scores) = If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097. ———————————————————————————————————————————————————————————————————————————————————— PATIENT HEALTH QUESTIONNAIRE 9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer) 0 — Not at all 1 — Several days 2 — More than half the days 3 — Nearly every day 1. Little interest or pleasure indoing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or havinglittle energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 FOR OFFICE CODING _+_+_+_ = Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. ———————————————————————————————————————————————————————————————————————————————————— Generalized Anxiety Disorder 7-item (GAD-7) scale Date: _______________ Name: _____________________________________ DOB: _______________ Over the last 2 weeks, how often have you been bothered by the following problems? 0 — Not at all 1 — Several days 2 — More than half the days 3 — Nearly every day 1. Feeling nervous, anxious, or on edge 0 1 2 3 2. Not being able to stop or control worrying 0 1 2 3 3. Worrying too much about different things 0 1 2 3 4. Trouble relaxing 0 1 2 3 5. Being so restless that it's hard to sit still 0 1 2 3 6. Becoming easily annoyed or irritable 0 1 2 3 7. Feeling afraid as if something awful might happen 0 1 2 3 Add the score for each column _+_+_+_ Total Score (add your column scores) = If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097. ———————————————————————————————————————————————————————————————————————————————————— PATIENT HEALTH QUESTIONNAIRE 9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer) 0 — Not at all 1 — Several days 2 — More than half the days 3 — Nearly every day 1. Little interest or pleasure indoing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or havinglittle energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 FOR OFFICE CODING _+_+_+_ = Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. ———————————————————————————————————————————————————————————————————————————————————— Generalized Anxiety Disorder 7-item (GAD-7) scale Date: _______________ Name: _____________________________________ DOB: _______________ Over the last 2 weeks, how often have you been bothered by the following problems? 0 — Not at all 1 — Several days 2 — More than half the days 3 — Nearly every day 1. Feeling nervous, anxious, or on edge 0 1 2 3 2. Not being able to stop or control worrying 0 1 2 3 3. Worrying too much about different things 0 1 2 3 4. Trouble relaxing 0 1 2 3 5. Being so restless that it's hard to sit still 0 1 2 3 6. Becoming easily annoyed or irritable 0 1 2 3 7. Feeling afraid as if something awful might happen 0 1 2 3 Add the score for each column _+_+_+_ Total Score (add your column scores) = If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097. ———————————————————————————————————————————————————————————————————————————————————— #SAMARITANS ———————————————————————————————————————————————————————————————————————————————————— [https://www.mind.org.uk/] Mind Information & Support About Us News & Campaigns Get Involved Workplace Shop Search Search Coronavirus: Find our information and support and more on our work Are you a young person? If you're going through a tough time, you're not alone. We've got lots of information and advice to help. How can we support you? I want... Enjoy some me-time with a Pause box Try Pause, our monthly subscription box. A mindful activity straight to your door. We're fighting for mental health. For support. For respect. For you. Information and support When you're living with a mental health problem, having access to the right information is vital. Go to our information pages to find out more. Find information and support Helping someone else It can be hard to know what to do when supporting someone with a mental health problem. Our information includes helpful advice on giving support. Find advice Ways to get involved Campaign We'll fight your corner. We believe everyone with a mental health problem should be able to access excellent care and services. Join our team of over 40,000 campaigners. Volunteer Give your time supporting in our offices or shops, reviewing our information, cheering on our fundraisers, sharing your story, talking to the media or as a Youth Voice Network member. Donate or fundraise Nobody should face a mental health problem alone. We need your help so we can be there – on the other end of the phone, in local communities and campaigning hard. Become a member Our members are at the heart of our work. Join Mind today, add your voice and become part of a movement for better mental health across England and Wales. Where your money goes 119,000 queries answered by our helplines in 2019–20 88p from every £1 we receive we spend on our charitable work 18m people accessed our information in 2019–20 You can find out more about our work in our 2019/20 annual review Support when you need it most Local Minds Local Minds provide mental health services in local communities across England and Wales. Side by Side Side by Side is a supportive online community where you can listen, share and be heard. “If it wasn't for Mind I wouldn't be here now. I will never forget their part in my recovery.” Mind in the media Thursday, 13 January 2022 Benefits assessments continue to fail people with mental health problems, according to expert evidence Mind’s Director of External Relations, Sophie Corlett, has given evidence to the Work and Pensions Committee on health assessments for disability benefits Employment and Support Allowance (ESA) and Personal Independence Payment (PIP). Thursday, 13 January 2022 Mind supports Ombudsman call for more than 118,000 people with disabilities to be compensated after their benefits were wrongly cut off Tuesday, 11 January 2022 UK Government must commit to increasing investment in services as Lord Stevens tables amendment to Health and Social Care Bill Mental health charity Mind has called upon the Government to increase expansion of NHS services if it is serious about mental health and the increased need caused by Covid. Call Mind Infoline 0300 123 3393 Legal information Privacy policy Terms and conditions Contact us Helplines Working with us Working for us Vacancies and volunteering Accessibility © 2022 Mind We're a registered charity in England (no. 219830) and a registered company (no. 424348) in England and Wales. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> [https://www.mind.org.uk/need-urgent-help/using-this-tool] Mind Information & Support About Us News & Campaigns Get Involved Workplace Shop Search Search Coronavirus: Find our information and support and more on our work Home>Need urgent help>Using this tool Get help now If you feel like you might seriously harm yourself or attempt suicide, you need urgent medical help. If you are in crisis but it's not a medical emergency, you might find our crisis resources helpful. Call or email our confidential Infoline or Legal line to ask us about mental health and related legal issues. If you want to learn more about a specific topic, you might find it covered in our A-Z of mental health. Call Mind Infoline 0300 123 3393 Facebook Instagram Twitter Youtube Legal information Privacy policy Terms and conditions Contact us Helplines Working with us Working for us Vacancies and volunteering Accessibility Mind Fundraising Regulator © 2022 Mind We're a registered charity in England (no. 219830) and a registered company (no. 424348) in England and Wales. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> [https://www.mind.org.uk/information-support/guides-to-support-and-services/crisis-services/getting-help-in-a-crisis/] Mind Information & Support About Us News & Campaigns Get Involved Workplace Shop Search Search Coronavirus: Find our information and support and more on our work× Home>Information & Support>Support and services>Getting help in a crisis How to get help in a crisis This page is also available in Welsh. If your life is at risk right now If you feel like you might attempt suicide, or may have seriously harmed yourself, you need urgent medical help. Please: call 999 for an ambulance go straight to A&E, if you can or call your local crisis team, if you have their number. If you can't do this by yourself, ask someone to help you. Mental health emergencies are serious. You're not wasting anyone's time. What about coronavirus? If you're worried about going to A&E because you're shielding or self-isolating, call 999 and ask for an ambulance to come to you. The NHS still wants you to get the right help in an emergency. This may mean going to hospital. "To this day I am so thankful that I was told to go to A&E. Sometimes you need to hit a low in order to move on from one." If you don't want to call 999 If you can keep yourself safe for a short while, but you still need urgent advice: contact NHS 111 if you live in England contact NHS 111 or NHS Direct (0845 46 47) if you live in Wales contact your GP surgery and ask for an emergency appointment. Many GPs are now offering these remotely because of coronavirus contact a local urgent mental health helpline. These are only currently available in England. Do you need some urgent coping tools? We have some crisis resources that you can use right away, by yourself, wherever you are. If you need to talk right now Whatever you're going through, there are people you can talk to any time. You can: call Samaritans on 116 123 (UK-wide) text SHOUT to 85258 (UK-wide) call C.A.L.L. on 0800 132 737 (Wales only) These services are for anyone who's struggling. They won't judge you. They're free, they're anonymous, and they're always open. Our page of helplines and listening lines has more numbers to try. "Once a girl actually answered the phone and kept me talking through my thoughts and suicidal feelings for almost three hours! To her I shall be eternally grateful!" If you want to help someone else See our information on how to help someone else in an emergency. Going to A&E in a crisis "I could have just tidied myself up and gone to work but somehow I knew I had to speak to a doctor." How can I prepare for a crisis? When you're feeling in crisis, you just need to focus on staying safe, and getting help. But if you have moments when you're feeling calmer and less overwhelmed, we have more information that could help you. Learn about crisis services Was this page useful? This information was published in June 2020. We will revise it in 2021. Need more support with this issue? Our helplines are here for you. Need the references and evidence sheet for this page? Contact our publishing team. Want to reproduce content from this page? See our page on permissions and licensing. Share this information Facebook Twitter Email More CAMPAIGNING VOLUNTEERING MEMBERSHIP Call Mind Infoline 0300 123 3393 Legal information Privacy policy Terms and conditions Contact us Helplines Working with us Working for us Vacancies and volunteering Accessibility © 2022 Mind We're a registered charity in England (no. 219830) and a registered company (no. 424348) in England and Wales. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> [https://www.mind.org.uk/need-urgent-help/] Mind Information & Support About Us News & Campaigns Get Involved Workplace Shop Search Search Coronavirus: Find our information and support and more on our work Home>Need urgent help Ways to help yourself cope in a crisis Practical tools to use right now, by yourself, wherever you are. If you're feeling in crisis, this resource is for you. Trying these practical tips might help if you're feeling overwhelmed or out of control. If you are finding it difficult to deal with how you're feeling right now, you shifting your attention onto something else might help. Reading about what your experiences mean might help you make sense of them. Finding out other people's stories may help you feel less alone. You deserve help and support. If you're not sure where to go, here are some ideas. If you feel unable to keep yourself safe, it's a mental health emergency. Was this page useful? Call Mind Infoline 0300 123 3393 Legal information Privacy policy Terms and conditions Contact us Helplines Working with us Working for us Vacancies and volunteering Accessibility © 2022 Mind We're a registered charity in England (no. 219830) and a registered company (no. 424348) in England and Wales. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> [https://www.mind.org.uk/need-urgent-help/what-can-i-do-to-help-myself-cope/] Mind Information & Support About Us News & Campaigns Get Involved Workplace Shop Search Search Home>Need urgent help>What can I do to help myself cope What can I do to help myself cope? If you're feeling overwhelmed or out of control, you might want to try different methods of calming yourself down. There are some specific strategies that a crisis team might try to use with you to manage and minimize any symptoms you might be experiencing. Coping techniques are simple exercises that try to accept, address and reduce the things you are experiencing. I want to try... Making a plan for the next few hours If you are finding it difficult to focus or are unsure how to manage your day, writing down what you'll do next might help you feel more in control of the situation. Try our step by step tool for getting through the next few hours Relaxing and calming exercises If you are feeling anxious or scared there are many things you can do to help yourself cope. Here are some simple exercises you can try that might calm you down. Coping with scary thoughts Some people experience thoughts that are frightening or alarming you. They could be about suicide, harming yourself, harming others, or hearing voices. We've put together a few ways that help people cope with unsettling thoughts. Was this page useful? Call Mind Infoline 0300 123 3393 Legal information Privacy policy Terms and conditions Contact us Helplines Working with us Working for us Vacancies and volunteering Accessibility © 2022 Mind We're a registered charity in England (no. 219830) and a registered company (no. 424348) in England and Wales. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> [https://www.mind.org.uk/need-urgent-help/what-can-i-do-to-help-myself-cope/getting-through-the-next-few-hours/ Mind Information & Support About Us News & Campaigns Get Involved Workplace Shop Search Home>Need urgent help>What can I do to help myself cope>Getting through the next few hours Getting through the next few hours If you are finding it difficult to focus or are unsure how to manage the next few hours, writing down what you'll do next might help you feel more in control of the situation. Once you've gone through it, it might be helpful to save your plan to help you remember in case you're struggling again in the future. This is completely anonymous, you don't need to share it with anyone, and everything you write down will be erased as soon as you close the window. Get through 5 minutes.... Try and think short term. Just think about getting through this one step. Look at a clock and see what the time it will be at the end of this activity and focus on that. Try not to think about what to do afterwards. Here are some suggestions by people who have been through something similar to what you're feeling right now, but if they've worked for someone else, maybe they will work for you. - Listen to a 5 minute song - Do this 5 minute meditation - Read one page of a book or magazine - Make a hot drink - Put some moisturiser on - Stroke a pet - Do some star jumps - Do this 5 minute breathing exercise In the next 5 minutes I am going to... Ready to try 10 mins? - Yes, that was ok - No, that was too hard - I'm not sure Would you like to keep your answers somewhere safe? No one but you will see it and everything you write down will be erased as soon as you close the window. Email address ________________ -- We do not endorse anything we link through to from this form. Everything has been suggested from people with experience of going through a mental health crisis. If you are worried about the content of anything listed here, please let us know at digidev@mind.org.uk and we'll look into it as soon as we can. Was this page useful? Call Mind Infoline 0300 123 3393 Legal information Privacy policy Terms and conditions Contact us Helplines Working with us Working for us Vacancies and volunteering Accessibility © 2022 Mind We're a registered charity in England (no. 219830) and a registered company (no. 424348) in England and Wales. ———————————————————————————————————————————————————————————————————————————————————— [https://www.thecalmzone.net/] NEED HELP? CALL OUR HELPLINE 5pm–midnight, 365 days a year GET SUPPORT GET INVOLVED DONATE FUNDRAISE ABOUT SEARCH We’re Campaign Against Living Miserably (CALM) and we’re united against suicide. That means standing against feeling shit, standing up to stereotypes, and standing together to show life is always worth living. Stand with us. Join the campaign and help us make sure everyone gets the support they need, no matter what. Your email EVENTS > London Winter Walk 2022 TAKE ACTION > How you can support CALM in 2022 FEATURES > Seven Ways to Stick It To Winter UNITED AGAINST SUICIDE > Anyone Can Feel Suicidal DONATE GET HELP ON > Feeling Lonely? We're here FEATURES > Meet the Movement Against Suicide: Ella’s Story FEATURES > Alex Lawther and Linus Fenton chat creativity and friendship FEATURES > Money on your mind? You’re not alone Make a donation Donate About CALM Privacy Statement Cookie Policy Helpline Confidentiality Policy Helpline Privacy Policy Charity reg no 1110621 and SC044347. Copyright CALM © 2022. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> [https://www.thecalmzone.net/help/get-help/] NEED HELP? CALL OUR HELPLINE 5pm–midnight, 365 days a year GET SUPPORT GET INVOLVED DONATE FUNDRAISE ABOUT SEARCH THINGS CAN GET TOUGH, BUT WE CAN HELP YOU GET YOUR LIFE BACK. BEING SILENT ISN’T BEING STRONG. CALL THE CALM HELPLINE 0800 58 58 58 Sorry, but our helpline is now closed OPEN 5PM – MIDNIGHT 365 DAYS A YEAR. Our helpline is for people in the UK who are down or have hit a wall for any reason, who need to talk or find information and support. For more info about our helpline service, visit our helpline information page. If you need immediate help, please call emergency services on 999 or The Samaritans on 116 123 *We’re supporting more people than ever through this challenging time and taking more calls and webchats than usual. This might mean there is a delay when getting in touch with us, but rest assured we’re here and ready to talk. WEBCHAT Sorry, but our webchat is now closed OPEN 5PM – MIDNIGHT 365 DAYS A YEAR. Our webchat is for people in the UK who are down or have hit a wall for any reason, who need to talk or find information and support. *We’re supporting more people than ever through this challenging time and taking more webchats than usual. This might mean there is a delay when getting in touch with us, but rest assured we’re here and ready to talk. For more info about our webchat service, visit our webchat information page. If you need immediate help, please call emergency services on 999 or The Samaritans on 116 123. FIND HELP ON SPECIFIC ISSUES Our helpline and webchat are open 5pm – midnight 365 days a year, and we can talk to you about whatever is getting you down. There are additional organisations around the UK that can also help you with specific issues. You can explore those organisations here EXPLORE ISSUES Want to learn more about something specific that’s getting you down? Our issues pages cover a lot of the issues that we often discuss over our helpline and webchat. This information can help you understand the issues you face and show you some other organisations that can provide additional help. Explore the information by clicking one of the issues on the right. ABUSE ALCOHOL AND DRUGS ANGER ANXIETY BIPOLAR DISORDER BODY IMAGE BULLYING DEPRESSION EATING DISORDERS ERECTILE DYSFUNCTION EXAM STRESS FINANCIAL STRESS GAMBLING GRIEF HAIRLOSS HEARING VOICES HOMELESSNESS LONELINESS AND SOCIAL ISOLATION MASTURBATION WORRIES MENTAL HEALTH OCD PTSD RACISM RELATIONSHIP BREAKDOWN SELF-HARM SEXUALITY SUICIDAL THOUGHTS SUPPORT AFTER SUICIDE TERMINAL ILLNESS WORK ISSUES We are all incredible beings, and there’s no shame in feeling a little down every now and then. There is a place, and there are people, you can turn to when you feel like there isn’t. That place is CALM. RKZ, DJ & MUSICIAN Make a donation Donate About CALM Privacy Statement Cookie Policy Helpline Confidentiality Policy Helpline Privacy Policy Charity reg no 1110621 and SC044347. Copyright CALM © 2022. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Webchat is now open - Hi there, This is an automated chat to help you find what you’re looking for. CALM’s helpline services are open from 5pm to midnight everyday. You can connect to a webchat with a member of helpline staff or ask a question below: You've chosen to start CALM's free, anonymous and confidential webchat. By continuing, you agree with our Privacy & Confidentiality policies. You can read them in full below: Confidentiality Policy Privacy Policy - Have you spoken to the CALM helpline before? (Helpline staff can not access previous conversations unless you use your return user code.) Before your session starts, we'd like to ask you a few questions. Your answers will help us to support you and improve our services. Please fill out our pre-chat questionnaire. • Which gender identities describe you most accurately? • Please select your age: • Please select your location: - Hi, welcome to CALM webchat. We can offer support, info and signposting. We try to keep our chats to about an hour, if that's ok. What would you like to talk about? - Thank you. While you're waiting to connect to a member of helpline staff, use the input field below to search the CALM site for support and information - Hi, welcome to CALM webchat. We can offer support, info and signposting. We try to keep our chats to about an hour, if that's ok. What would you like to talk about? - Hi, are you there? - How has your day been? - We're sorry to hear that you have struggled with suicidal thoughts again. Can we ask, do you think something my have happened to trigger these? - Gosh this sounds very isolating for you. Do you have someone that you feel able to speak with? - We are glad that you feel able to speak with us. We understand how difficult mental health can be. More so when experiencing suicidal thoughts. How long would you say you have thought this way for? - We're sorry to hear these didn't help. Please don't be too startled or disturbed by experiencing suicidal thoughts. It is common for our minds to fantasise suicide when we feel overwhelmed or stressed. Having these suicidal thoughts bring the mind some time to escape how you're feeling. The mind can be a very strange at times with how it can operate. - Gosh it sounds like you have struggled with this for some time now. We are sorry to hear that your thoughts have progressed to ideation, this must be very difficult for you. We hope that being able to differentiate between thoughts, ideation and intent brings you a form of comfort. Have you ever found anything along the way that helps you when you reach these darker periods of depression? - Wow, how interesting. Do you know why it is that your body reacts in this way? - Okay, we hear this is due to a form of shock or survival mode. Gosh this must be scary for you at times? - We are here with you to support you through this. Have you ever thought of attending a suicide sanctuary or crisis house before? - We can understand how difficult signposting can feel, especially when struggling with suicidal ideation and depression. There are however other great organisations that can give you more tailored support if this is what you are looking for, and we can help you with finding these. Here at CALM we support, provide information and signpost. We are similar to Samaritans in this respect and are here for you every evening to be able to have someone to talk to 5-12. With regards to help or more tailored support, Maytree is brilliant for this with a suicide sanctuary option www.maytree.org.uk/ Mind also offer further support as well as crisis houses that can offer in person support www.mind.org.uk/information-support/guides-to-support-and-services/crisis-services/crisis-houses/ - With how you are feeling, it might be a great idea for you to reach out to them? These places seem to offer what it is you might be looking for. We are here for you to talk whenever you need someone. - We understand how frustrating it can be when trying to locate the right kind of help that you feel would support you through this. Please do not feel that we are passing you on, we would never pass you on, we are here to support you, talk with you, provide information and relevant signposting also for your needs. We can see how difficult this is for you and wouldn't want you thinking that we were simply 'passing you over'. We know these two organisations can offer a more hands on approach which it seems you may be looking for. - Can we ask, do you find that talking helps? - We apologise if we have offended in any way this was never our intention. Please know that we were not passing you on. In answer to your question when you asked how can we help you, we can support you, talk with you, provide information and signpost. Do you know what kind of help it is that you would find might work for you? If not, maybe we can help with this? - You mentioned earlier that you have nobody you feel able to speak with. We recognise how important it is to be able to speak to someone. This being said, we are here to speak with you, to bring clarity, support, a listening ear to help you through this. We can provide information to help you also with understanding your current situation and how to manage, heal and/or cope with this. With regards to signposting, we understand how this can appear to be passing a person on. We cannot be more honest when saying this is not what signposting is for us. We know and trust the organisations that we are able to signpost people to. We would never signpost if we didn't feel that organisation could help in a different way than we are able to with what a person is experiencing. - We do apologise for any miscommunication, when we asked if you have someone that you feel able to speak to with regards to a support system around you, we received your response 'Not about this. Hence me being here now'. We apologise if we may have read this the wrong way. - We understand, please know that we are here and able to speak with you about this. We recognise how difficult this must be to open up about. - Thanks for using CALM webchat. We hope it has been helpful. Please know that we are here for you during this. Best wishes from CALM If you'd like to chat to the CALM helpline again, please note your unique code. Helpline staff will be able to use it to recognise you next time you chat. Your unique code is: ***** Thank you for using the helpline. Please take a few moments to complete our questionnaire, it will only take a few minutes. Your responses are very important to us and will help us to improve this service. Post-Chat Questionnaire Your responses are anonymous and can't be seen by the helpline staff. Were you able to speak to someone today? What were you hoping to get out of your webchat? (select all that apply) • An opportunity to offload • Someone to talk through issues with • Someone to listen • Information on where to find help • Advice and/pr positive action plan • Info on how to help someone else • I don't know • Other (Please add below) How do you feel now, compared to how you felt before your chat? If you were given information or advice, did you find it useful? Did you find using CALM's webchat helpful today? If you need help in the future, would you come to CALM again? Would you recommend CALM's webchat? Did you have any technical difficulties during your webchat? (broken page, chat quit unexpectedly etc.) Any other comments Please provide any other comments here. I am happy for my comments to be used anonymously across private and public platforms to further the work of CALM. SUBMIT / SKIP Thanks. If you'd like to find out more about CALM, you can ask a question below. CONNECT TO HELP LINE / ASK CALM A QUESTION ———————————————————————————————————————————————————————————————————————————————————— PATIENT HEALTH QUESTIONNAIRE 9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer) 0 — Not at all 1 — Several days 2 — More than half the days 3 — Nearly every day 1. Little interest or pleasure indoing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or havinglittle energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 FOR OFFICE CODING _+_+_+_ = Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. ———————————————————————————————————————————————————————————————————————————————————— Generalized Anxiety Disorder 7-item (GAD-7) scale Date: _______________ Name: _____________________________________ DOB: _______________ Over the last 2 weeks, how often have you been bothered by the following problems? 0 — Not at all 1 — Several days 2 — More than half the days 3 — Nearly every day 1. Feeling nervous, anxious, or on edge 0 1 2 3 2. Not being able to stop or control worrying 0 1 2 3 3. Worrying too much about different things 0 1 2 3 4. Trouble relaxing 0 1 2 3 5. Being so restless that it's hard to sit still 0 1 2 3 6. Becoming easily annoyed or irritable 0 1 2 3 7. Feeling afraid as if something awful might happen 0 1 2 3 Add the score for each column _+_+_+_ Total Score (add your column scores) = If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097. ———————————————————————————————————————————————————————————————————————————————————— Dear _________, Following our call today, please see attached your appointment letter, along with the crisis plan we discussed. Kind regards, Daniel Dowling Trainee Psychological Wellbeing Practitioner Lambeth Talking Therapies (Lambeth IAPT), 1a Dalbury House | Edmundsbury Estate | Ferndale Road | London| SW9 8AP Client opt-in line: 0203 228 6747 For information and self-help material, please visit our website: www.slam-iapt.nhs.uk/lambeth For information about other services, see our website: www.slam-iapt.nhs.uk/lambeth. Continue to the bottom of the page and click on 'Community and Services Guide' under the downloads tab Interested in research? Lambeth Talking Therapies is collaborating with theGenetics Link to Anxiety and Depression (GLAD) study to better understand anxiety and depression and improve treatment for future patients. Please visitwww.gladstudy.org.uk for more information and to sign up. ———————————————————————————————————————————————————————————————————————————————————— Lambeth Talking Therapies 1a Dalbury House Edmundsbury Estate Ferndale Road London SW9 8AP www.slam-iapt.nhs.uk Crisis Plan Mr/Ms XXXXXX XXXXX This is my plan to look at when I am in crisis and need support. It is my plan to follow and has the numbers and ideas to help me. When I am feeling I want to end my life, and I think what is the point, when everything is overwhelming, and I see ending my life is a comfort. The first thing I will do is: - To shock myself with ice cold water - I will take time in my bed, waiting for the feeling to pass - I can force myself to leave bed without thinking and just walk and walk When I am feeling like this, I will remind myself of my family, friends, girlfriend, and my passions - anything around food and art When I am feeling like this, I will tell my girlfriend or parents, but at times I feel like I do not want to bother them. Step-by-step plan of what to do immediately if you feel suicidal / at risk: 1) Call your emergency contact Andrea 07756153755(Friend) 2) If during daytime hours, call your GP for an emergency appointment 3) If after working hours, due to COVID-19 and high pressure on A&E departments, if you are in a mental health crisis, please do not visit your A&E department, please contact the Samaritans (116123) or the SLAM 24 hour line (0800 731 2864). Other emergency contacts I can use: - Samaritans, 24 hours, on 116123 or email: jo@samaritans.org - Solidarity in Crisis - (out-of-hours peer support service) Mon-Friday 6pm-12am and Sat-Sunday 12pm-12am. Tel. 0300 1231922 (freephone) or text 07889156087 or 0779756083 - Email: outofhours-solidarity@certitude.org.uk - SLaM mental health support line on 0800 731 2864 - 7 Cups - Website: https://www.7cups.com/ If I don’t show up to my appointment or my clinician is worried about me, they can contact XXXXXXXXX My plan for now is to wait, focusing on the idea that I will receive support, stay at home, keep calm and continue to work. Tips for coping right now: • Try not to think about the future – just focus on getting through today • Stay away from drugs and alcohol • Get yourself to a safe place, like a friend's house • Be around other people • Do something you usually enjoy, such as spending time with a pet • You can download the StayAlive app Clients Signature: Clinicians Signature: Daniel Dowling 10 Jun 2020 Powered by TCPDF (www.tcpdf.org) ———————————————————————————————————————————————————————————————————————————————————— Lambeth Talking Therapies 1a Dalbury House Edmundsbury Estate Ferndale Road London SW9 8AP www.slam-iapt.nhs.uk 10 June 2020 Private & Confidential Mr/Ms XXXXX XXXXXX XX XXXXXX XX London XXX XXX Dear Mr/Ms XXXXXX, After your telephone discussion with us an appointment has been made for you to start a course of therapy via virtual clinics with Joe Hand 07791231311. Your first session will be on Thursday 18th June 2020 at 09:15 There are full details with how to set up the virtual clinics on the next page. Please complete the email questionnaires that you will receive the day before the appointment. If you are unable to attend please call or email Joe Hand 07791231311. If you do not attend and do not let us know in advance, you will not be offered another appointment. If you are late for your session we might not be able to see you, and this would also count as a missed appointment. Please note that you are expected to attend your appointment on a weekly basis (at the same time and day) after your first appointment. If you feel that CBT is not the right treatment for you then it would be helpful to discuss this with your therapist or email LambethIAPTAdministrators@slam.nhs.uk.We have a number of different treatment options in the service and would be happy to discuss these with you. Please read the notes about treatment on the next page and do not hesitate to get in touch with us if you would like to discuss this further. As a result of remote working due to COVID-19, our main phone line will be closed over this period until further notice. If you need to cancel an appointment or have any questions, please contact your therapist directly or email our administrative team on LambethIAPTAdministrators@slam.nhs.uk. Yours sincerely, Daniel Dowling (Daniel.Dowling@slam.nhs.uk) Trainee Psychological Wellbeing Practitioner cc: Sandmere Practice, 10-14 Sandmere Road, Clapham, London, SW4 7QJ Guidance for virtual clinic appointments You have been booked in to complete a course of therapy via virtual clinics with Lambeth Talking Therapies. Each session you and your therapist will log in via Microsoft Teams to have your appointment. There is no change to the length of therapy sessions or the content covered by having virtual sessions. Please make sure that you have workable technology (any smart device with a built in camera) to complete these appointments, and that you can be somewhere private for the duration of the appointment. You and your therapist will also be able to share documents and homework via the programme. Instructions for set up • Check both main inbox and junk mail. If no invitation received please contact your therapist or our main admin inbox: LambethIAPTAdministrators@slam.nhs.uk • Please ensure you are in a suitable area where you can complete the session • A private room where you cannot be over heard or interrupted • Area with good network coverage How to prepare for the appointment • Ensure your device is sufficiently charger i.e. 50% + • You need any smart device with a built in camera • May need to download Microsoft Teams App for the first time, in advance of the appointment, this can be reused for future appointments • We recommend using headphones for better quality sound Suitable Network Connections • Wi-Fi • Wired Connection • Mobile Network i.e. 4G, 3G At the time of appointment, you must ensure you: • Click on the purple link ‘Join Microsoft Teams’ sent in the email or text • Click on the ‘Join as Guest’ button when prompted to do so • Accept permission requests when prompted • Enable your Camera and Mic with the Teams App • Where prompted for a name: type in your name (the name known and agreed between you and your Clinician) • If name is NOT recognised by the admin/clinician you will not be connected to a clinician • Clinicians can request for further ID and make ask the following to confirm: • Full Name • DOB • Postcode If it’s not working • In the unlikely event that connection is lost wait 1 minute for connection to automatically be re-established or re-join if prompted. If after 5 minutes of no connection disconnect and the clinician will call you instead. Important information about your appointments First appointment Your first appointment is for an assessment. At the end, we will discuss with you what help may best meet your needs. We will inform your GP (or any other professional who referred you) what we have decided to offer, and the outcome of the treatment. Urgent help We are not an emergency service. Due to COVID-19 and high pressure on A&E departments, please do not go to your local A&E if experiencing a mental health crisis. For urgent help, please contact your GP for an emergency appointment or SLaM Mental Health Support 24-hour helpline on 0800 731 2864 Other crisis services you can use: Samaritans 24 hour helpline on 116 123 or email jo@samaritans.org, Solidarity in A Crisis (freephone) on 03001231922, Lambeth Short Term Support Service on 0800 0902456, or The Listening Place http://listeningplace.org.uk/contact-us/ which is a service run by volunteers supported and supervised by mental health professionals. Our attendance policy If you are unable to attend please call or email Joe Hand 07791231311. If you cannot get through to them please contact one of the team administrators at LambethIAPTAdministrators@slam.nhs.uk For the treatment to work, you need to have regular appointments. If you do not attend your appointment, and do not call us beforehand to cancel and let us know, you may lose that session. If this happens again, you will be discharged and will not be offered another appointment. If there are major unavoidable reasons that stop you coming, please let us know and cancel before the appointment. If you are late for your session we might not be able to see you, and this would also count as a missed appointment. If you have to cancel two appointments, you will be discharged and treatment will end. You may then be able to restart treatment at a later date when you know you can attend regularly. Confidentiality The information you give is confidential within the NHS. That means it is not disclosed outside of the NHS unless we have your permission. However, we will inform other people if we think you are at risk to yourself or to other people. For example if we were concerned that you may be about to harm yourself or another adult or child. Then we would be required to inform other authorities. Questionnaires Your therapist will ask you to complete questionnaires about how you are feeling and doing, every week. This is essential so that we can keep track of your progress. They will also ask you to do other tasks in your week, including completing diaries for homework. This is to make sure that what we do works in your everyday life. Research opportunity If you are interested in taking part in research, Lambeth Talking Therapies is collaborating with the Genetic Links to Anxiety and Depression (GLAD) Study. This would allow you to take part in research studies about psychological wellbeing and talking therapies. The goal is to better understand anxiety and depression and to improve treatment for anyone who has experienced these difficulties. For more information, see the attached leaflet or visit www.gladstudy.org.uk. What is Cognitive Behavioural Therapy (CBT)? CBT is a type of talking treatment that focuses on how your thoughts, beliefs and attitudes affect your feelings and behaviour, and teaches you coping skills for dealing with different problems. Unlike some of the other talking treatments, it focuses on the 'here and now' and looks for ways to improve your state of mind in the present. How is CBT delivered? CBT can be done individually or with a group of people. It can also be done from self-help materials or an online computer programme. What to expect in sessions • CBT is a structured approach where you would agree with your therapist which problems you want to focus on and what your goals are. • It can be easy to talk about doing something different but much harder to actually do it. CBT is about ‘doing’ therapy rather than ‘having’ therapy. • During the sessions, you will work through exercises to explore your thoughts, feelings and behaviours. This may be in the form of diagrams, worksheets or booklets. • With CBT you will be given work to do in your own time, so at the end of each session you might agree on some exercises to work on for ‘homework’ before the next session so you can practise these changes in your everyday life. This is a crucial part of CBT so in order for it to be effective, you do need to be able to commit your own time to complete the work over the course of treatment, and afterwards. How effective is CBT? • It is one of the most effective treatments for conditions where anxiety or depression is the main problem. • The strength of CBT is that you can continue to practise and develop your skills even after the sessions have finished. This makes it less likely that your symptoms or problems will return. If you would like some more information about what to expect from therapy sessions please visit http://www.supportingsafetherapy.org/. References: Making sense of CBT - Mind Cognitive behavioural therapy (CBT) - Royal College of Psychiatrists ———————————————————————————————————————————————————————————————————————————————————— Dear Colleagues, Please see the attached letter and crisis plan regarding one of the patient's your practice. Can you please confirm receipt of this email? Thank you! Kind regards, Daniel Dowling Trainee Psychological Wellbeing Practitioner Lambeth Talking Therapies (Lambeth IAPT), 1a Dalbury House | Edmundsbury Estate | Ferndale Road | London| SW9 8AP Client opt-in line: 0203 228 6747 For information and self-help material, please visit our website: www.slam-iapt.nhs.uk/lambeth For information about other services, see our website: www.slam-iapt.nhs.uk/lambeth. Continue to the bottom of the page and click on 'Community and Services Guide' under the downloads tab Interested in research? Lambeth Talking Therapies is collaborating with theGenetics Link to Anxiety and Depression (GLAD) study to better understand anxiety and depression and improve treatment for future patients. Please visitwww.gladstudy.org.uk for more information and to sign up. ———————————————————————————————————————————————————————————————————————————————————— Dear XXXXXXXXX, Please read up to page 12 and fill in page 12 making a note of what you are doing day to day and your mood. https://cedar.exeter.ac.uk/media/universityofexeter/schoolofpsychology/cedar/documents/BA_Control.pdf Thanks Joe Kind Regards Joe Hand Triage Manager/Senior Psychological Wellbeing Practitioner South London and Maudsley NHS Foundation Trust Lambeth Talking Therapies (Lambeth IAPT) 1a Dalbury House| Edmundsbury Estate | Ferndale Road | London | SW9 8AP Main line: 0203 228 6747 Work mobile: 07791231311 Interested in research? Lambeth Talking Therapies is collaborating with the Genetics Link to Anxiety and Depression (GLAD) study to better understand anxiety and depression and improve treatment for future patients. Please visit www.gladstudy.org.uk for more information and to sign up. ———————————————————————————————————————————————————————————————————————————————————— Get Active Feel Good! Paul Farrand, Adrian Taylor, Colin Greaves & Claire Pentecost Helping yourself to get on top of low mood WELCOME AND WELL DONE! Sometimes the hardest steps are the first ones, and by getting this far you have already taken your first step to get on top of your low mood. This self-help programme, with Case Studies, is here to guide you through your recovery based on an approach that has helped many people already in a similar situation to you. At times you may feel like giving up, but don’t worry that is perfectly normal. If you can, use the support of a family member or friend, or maybe your GP, as well as your Psychological Wellbeing Practitioner, or PWP for short. Your PWP is a mental health professional trained to support you to work through this self-help programme. It is likely you will have regular sessions with them to help you identify and solve any problems and answer any questions you may have. The focus is on working together, rather than your PWP simply telling you what you should do. As such they will go at the pace you want to go and really put you in control. Remember you are the expert in how you are feeling. Their expertise is in supporting people as they use this programme. You are going to ask a lot of yourself in working through this programme, and at times you will simply want to give up. However it is likely your PWP has seen this all before and will be able to help you through any difficult times. There are no expectations about how quickly you should work, nor the amount of time it will take to get better. However, for this programme to be successful we ask you to commit to two things. • GIVE THE ACTIVITIES A GO TO SEE WHAT WORKS FOR YOU • STAY IN TOUCH, FACE-TO-FACE OR BY PHONE! LET YOUR PWP KNOW HOW YOU FEEL SO THEY CAN BETTER SUPPORT YOU HELPING YOU THROUGH YOUR TREATMENT Before we get started on helping you to understand low mood and the way it affects you, we would just like to share some tips that may be helpful when using this programme. Most of these tips come from people just like you who we have treated for low mood. GIVE IT YOUR BEST SHOT Because you have low mood you may find some things difficult. But just give the programme your best shot. Your PWP is there to help you overcome any difficulties you have and is well aware that sometimes things just seem too much. All anyone will ask of you is just to give it a go. LIKE EVERYONE, EXPECT TO HAVE GOOD DAYS AND BAD DAYS Hopefully after using the programme for a few weeks you will notice a gradual improvement in your mood. However, you will also have bad days, and this may affect how you use your programme or engage with the activities. This is all perfectly normal and to be expected. DON’T OVERDO IT Whilst treatment will proceed at a rate suitable for you, slow and steady is often the best to aim for. Think about breaking things down into small, manageable chunks – that generally makes things easier. Your PWP will be able to help you with this. INVOLVE FAMILY AND FRIENDS IF YOU CAN Like all of us, when you are feeling a little down, you may have found that just having others around can be helpful. They may help you look at things differently, find ways to solve problems or maybe just be there for a chat. Getting others involved isn’t for everyone and you may not be ready to take this step yet – don’t worry if that is the case. But if you think you might find the support of others helpful and they want to help then why not ask? If you show them this programme, they may find the sections on what low mood is and how it is affecting you helpful. UNDERSTANDING LOW MOOD AND DEPRESSION Persistent low mood, or as it is often called depression, will affect about one in six people during their lifetime. Mental health experts are still debating what causes depression and low mood. Some feel it is caused by: • Low levels of a chemical called serotonin that helps to take signals from one area of the brain to another • The way we interpret things that happen to us. If you tend to look at things negatively (especially ourselves, our futures and the world around us) or if you tend to jump to negative conclusions, over time this can affect your mood • A reduction in your normal activities, for whatever reason Whilst any of these may be true, it is very likely that most people become depressed due to a combination of them. So it may not be easy to pin it down to any one thing. INACTIVITY + UNHELPFUL THOUGHTS + ? + LOW SEROTONIN = DEPRESSION The Impact of Low Mood? Although everyone will experience depression in their own way, people often say similar things about it. People with depression often say that depression affects a) their behaviour, b) the thoughts that go through their head, and c) how they physically feel. One thing leads to another, as we have tried to show in the diagram opposite. You may not be experiencing all these things, but if you have depression you will certainly be experiencing some of them. The impact of low mood or depression BEHAVIOURAL Doing things differently or not doing the things you used to do, eating more or eating less PHYSICAL Tiredness, problems sleeping, crying, losing or gaining weight, problems concentrating, being irritable THOUGHTS Tend to be negative or unhelpful, such as feeling guilty, thinking you are useless, thinking the worst Depression or low mood impacts upon all three of these areas and one thing leads to another. For example, having unhelpful thoughts can make people feel tired and fatigued which may then stop them from doing the things they want or need to do. Or, problems concentrating can result in thoughts like ‘I can’t do anything properly anymore’ which could result in time off work. A very important thing about the above diagram is the way that these three areas can reinforce each other. It can become an unhealthy cycle, or a ‘downward spiral’ that is hard to break out of. These negative effects can spill over into other areas of your life. HOW IS YOUR DEPRESSION AND LOW MOOD AFFECTING YOU? People with depression or low mood may also report having a sense that ‘they are staring down a black hole, not knowing how to get out’. Before we start to talk about ways in which we can help you get out of this hole, it is worth thinking about how your depression or low mood is affecting you. Using the diagram opposite think about how your depression or low mood is affecting you. In each of the three boxes write in the type of things you have stopped doing or are doing differently, some of the unhelpful thoughts that commonly go through your head and the way you feel physically. Don’t worry if this seems difficult - your PWP will go through this with you. Behavioural Write in here the things you have stopped doing or now do differently __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Physical Write in here the physical changes you have noticed __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Thoughts Write in here the specific types of unhelpful thoughts that go through your head __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ THINKING AHEAD Hopefully you now know a little more about how your low mood is affecting you. It may therefore be helpful to begin to think about what you would like to get out of your treatment. Some people with low mood find it difficult to plan ahead but this will be an important part of your treatment. So, it would be useful for you to think about what you may be able to achieve over the next few months. These may be things you have done in the past that you have stopped doing, or new things you would like to achieve. OK let’s get started! In the ‘What do you want to get out of treatment?’ boxes opposite, write down three things you are not presently doing but would like to. Then say how well you think you can currently achieve them by circling the appropriate number between 0 and 6 (0 means ‘Not at all’ and 6 means ‘Anytime’). It should be something that you are not able to do at the moment but that you think you can realistically achieve over the coming months. If you are struggling to identify any aims for your treatment, your PWP can help. What Do You Want to Get Out of Treatment? Today’s Date: Item 1 __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ I can do this now (circle a number): 0 - Not at all 1 2 - Occasionally 3 4 - Often 5 6 - Anytime Today’s Date: Item 2 __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ I can do this now (circle a number): 0 - Not at all 1 2 - Occasionally 3 4 - Often 5 6 - Anytime Today’s Date: Item 3 __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ I can do this now (circle a number): 0 - Not at all 1 2 - Occasionally 3 4 - Often 5 6 - Anytime ———————————————————————————————————————————————————————————————————————————————————— PATIENT HEALTH QUESTIONNAIRE 9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer) 0 — Not at all 1 — Several days 2 — More than half the days 3 — Nearly every day 1. Little interest or pleasure indoing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or havinglittle energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 FOR OFFICE CODING _+_+_+_ = Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. ———————————————————————————————————————————————————————————————————————————————————— BEHAVIOURAL ACTIVATION : GETTING ACTIVE Now you have identified some things you would like to achieve by the end of your treatment, it is time to move on and think about ‘getting active’ to reduce your low mood. The way you will be supported to do this is through something called ‘Behavioural Activation’. This is a treatment that is often used to help people with low mood and depression. Why is Behavioural Activation used for depression and low mood? a) Lots of people with low mood have told us how helpful they have found it in improving their low mood. b) A lot of research has shown it to be effective. c) It does not require you to concentrate for long periods of time or think too much. These are both things that people with depression or low mood often tell us they have problems with. What will I need to do? It requires you to increase the things you are doing in three main areas of your life: • routine activities • pleasurable activities • necessary activities Just thinking about this may seem overwhelming as you are possibly struggling with low energy levels and tiredness. However, the really helpful thing about behavioural activation is that it is done in a way that helps you to start doing things again at a level you choose. You will decide how much you feel you can do. But I am already tired! By doing more activities you may also notice you slowly start to feel better and your tiredness actually begins to lessen. This may seem a bit odd. But sometimes we do less because we feel tired and less energetic. So how does it work? When people are depressed they tend to withdraw from the world in general. They tend to do less of the things they routinely do, things that they find pleasurable, or things that are necessary in life (such as paying the bills or doing the shopping). This might help at first as in the short-term doing less may actually make you feel better – it is a normal ‘self defence’ type of response. However, doing less in the longer term also means that things that have to be done tend to pile up and you may find yourself doing less of the things you enjoyed. You also have more time to dwell on negative thoughts. Cycle of low mood and reducing activity • You feel low and down, distressed, ill and have low motivation • You do fewer activities • You experience less fun and pleasure and have even less of a sense of achievement. Your energy levels begin to get even worse, you have poor sleep, difficulties concentrating and your general health worsens • You feel worse Over time, this lack of activity can make your mood worse rather than better. Then of course, you are likely to want to do even less and this makes you feel even worse – it is a downward spiral (or a black hole as some people describe it). Behavioural Activation tries to break this cycle by encouraging you to start doing things again – a little at a time. This puts the spiral into reverse and things start to improve. By taking small steps you will start to feel better and have more energy and more confidence to take the next step. Best of all, you are the one who will set the pace, and you are the person who will decide what to do and when. Getting started with Behavioural Activation People with depression and low mood often like Behavioural Activation. Have a go to try and work through this yourself, but as ever your PWP is there to help you as well. STEP 1 : RECORD WHAT YOU ARE CURRENTLY DOING Use the blank ‘My Starting Point Diary’ to record what you are currently doing during the week. Start today and record over the next 7 days. There are two boxes each for the morning, afternoon and evening so just try to include the main two things you have done for each. At the end of each day have a look at your diary and write any comments you have in the comments box. Think about what you have been up to, and try to note if there were times when you felt better or worse. This will help you and your PWP when you discuss your week at the next session. It can really help later on if you are able to provide some detail about: ‘What’ you are doing – i.e. ‘watching television’ ‘Where’ you are doing it – i.e. ‘lounge’ ‘Who’ you were with – i.e. ‘on my own’ My Starting Point Diary Monday Tuesday Wednesday Thursday Friday Saturday Sunday AM What _______________ _______________ _______________ _______________ _______________ _______________ _______________ Where _______________ _______________ _______________ _______________ _______________ _______________ _______________ Who _______________ _______________ _______________ _______________ _______________ _______________ _______________ - What _______________ _______________ _______________ _______________ _______________ _______________ _______________ Where _______________ _______________ _______________ _______________ _______________ _______________ _______________ Who _______________ _______________ _______________ _______________ _______________ _______________ _______________ - PM What _______________ _______________ _______________ _______________ _______________ _______________ _______________ Where _______________ _______________ _______________ _______________ _______________ _______________ _______________ Who _______________ _______________ _______________ _______________ _______________ _______________ _______________ - What _______________ _______________ _______________ _______________ _______________ _______________ _______________ Where _______________ _______________ _______________ _______________ _______________ _______________ _______________ Who _______________ _______________ _______________ _______________ _______________ _______________ _______________ - Evening What _______________ _______________ _______________ _______________ _______________ _______________ _______________ Where _______________ _______________ _______________ _______________ _______________ _______________ _______________ Who _______________ _______________ _______________ _______________ _______________ _______________ _______________ - What _______________ _______________ _______________ _______________ _______________ _______________ _______________ Where _______________ _______________ _______________ _______________ _______________ _______________ _______________ Who _______________ _______________ _______________ _______________ _______________ _______________ _______________ - Comments _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ ———————————————————————————————————————————————————————————————————————————————————— PATIENT HEALTH QUESTIONNAIRE 9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer) 0 — Not at all 1 — Several days 2 — More than half the days 3 — Nearly every day 1. Little interest or pleasure indoing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or havinglittle energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 FOR OFFICE CODING _+_+_+_ = Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. ———————————————————————————————————————————————————————————————————————————————————— STEP 2 : IDENTIFYING ACTIVITIES Once you have an idea as to what you have done during the previous week it is time to start to think about some of the things you have given up since feeling down. And perhaps to think of some things you would like to start to do for the first time. Looking at the three things you said that you would like to achieve previously in the ‘What Do You Want To Get Out of Treatment’ box may help you think about some of the things you want to put in here. Try to think about activities in three main areas of your life Routine These are activities you used to do regularly and can include things such as cooking, cleaning, shopping for food, walking the dog, shaving, washing, having a bath or shower etc. Pleasurable These are things you used to enjoy before your low mood or indeed could be new things that you think you would enjoy and like to try. These are very much down to individual choice. What one person enjoys another may really dislike. Only you can really know what these are, however examples may include going out with friends, or going to the park. Necessary These are activities that are often very important and for which there is a consequence if they are not done. For example, paying bills, getting an M.O.T. for the car, taking your children to school, ensuring you phone work to let them know how you are getting on or completing a Personal Sickness Certificate if you are off work. Use ‘Worksheet A’ on the next page to write down a few activities in each column. You do not have to do this all at once, and may find it helpful to come back to it a few times. At times you may be unsure as to whether the activity is Routine, Pleasurable or Necessary. Don’t worry about it – these categories overlap a lot. For example having a bath could fall into any of the categories. Just put the activity where you feel it fits best. Worksheet A : Identifying activities Under each type of activity write down what you want to be able to achieve. Please include all activities you can think of here, regardless of whether you think you can do them or not. We will deal with that in Step 3. Again don’t worry if you struggle with this step. Anything you get down will be a bonus as your PWP is always there to help. Routine Pleasurable Necessary e.g. cooking, walking e.g. going out with e.g. paying bills, taking the dog, food shopping friends, reading children to nursery ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ If you have managed to identify even a few activities in each column then that is great. You can move onto Step 3. If you have had some problems doing this however, your PWP will help. Worksheet B : Organising activities by how difficult they are Least difficult Medium difficul Most difficult ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ STEP 4 : PLANNING The final stage is to begin to put activities from your ‘Least difficult’ section into the ‘My Next Steps Diary’ over the page. As far as possible, try to include at least one Routine, Pleasurable and Necessary activity from the Least difficult column. However, the number of activities you think you can achieve can only be decided by you. Sometimes people may feel achieving just two or three to begin with is enough, especially if you have been inactive for a long time. Sometimes people may feel they can achieve more in a week. If you feel like this, great! However be prepared for the possibility that when you come to actually do the activities it may seem harder than you first imagined. If this is the case then it is no problem. Do what you can, and afterwards make a note of the difficulties or what you enjoyed in the Comments section in your ‘Next Steps’ Diary and discuss these when you next see your PWP. Important Although you should try to start off with the ‘Least difficult’ activities, have a look at your Necessary activities. Necessary activities may also need to be prioritised even if they are under your ‘Most difficult’ heading, as these may have consequences if they are not done. For example, it may be paying an overdue water bill. If you notice that it needs to be done in the next week then think about ways you could do it. Until you feel better this could involve asking friends or family for help, or if there is time you could raise this at your next meeting with your PWP who could help you to overcome any barriers to getting these done. Time to put the planned activity into action When you have managed to write your activities for next week in your diary it’s time to start getting active! Use the diary to help you to start doing the things you want to achieve at the times you have indicated. This may or may not be easy. But as long as you try to achieve the activities in your diary you will be making your first steps towards recovery. See how you get on in the first week. If you have struggled, then try to write down what happened and why it didn’t work in the comments box and your PWP will be able to support you. If however you have achieved the activities you set yourself write down why you think it worked then for next week you can start to think about including more activities. Perhaps you could start to include some of the activities that you originally saw as more difficult. If all is well then over time you will notice your diary beginning to fill up once again and you will notice yourself getting back to your regular activities. A few things to remember however! Don’t expect too much too soon Some weeks you may find are quite easy to achieve. Other weeks may be a real struggle or you may not achieve the activities you set yourself. This is all perfectly normal and to be expected. But either way is great; whatever happens you and your PWP are learning how best to move forward and you are learning how to steer your way back towards feeling better. Don’t expect to feel better immediately It can take time to get this ball rolling and you may find that you start to feel you have achieved things before you actually start to experience pleasure, satisfaction or a sense of achievement again. The main thing is just to keep going and the pleasure and sense of achievement will return. Don’t forget you are in control You should go at the speed you want. No-one is going to put you under any pressure to go quicker than you want to. Also remember you are not alone, your PWP is there to help you throughout. STEP 4 : PLANNING Planning activities for the week using My Next Steps Diary Diary. There are a few additional helpful tips on planning your activities • If possible try to plan your activities on different days, spreading them over the week. Do not try to overload yourself on one particular day and have nothing on other days. • Be as specific as possible when describing your chosen activities. As with the My Starting Point Diary try to include ‘What’ you are planning to do, ‘Where’ you are planning to do it and ‘Who’ you are planning to do it with. My Next Steps Diary Monday Tuesday Wednesday Thursday Friday Saturday Sunday AM What _______________ _______________ _______________ _______________ _______________ _______________ _______________ Where _______________ _______________ _______________ _______________ _______________ _______________ _______________ Who _______________ _______________ _______________ _______________ _______________ _______________ _______________ - What _______________ _______________ _______________ _______________ _______________ _______________ _______________ Where _______________ _______________ _______________ _______________ _______________ _______________ _______________ Who _______________ _______________ _______________ _______________ _______________ _______________ _______________ - PM What _______________ _______________ _______________ _______________ _______________ _______________ _______________ Where _______________ _______________ _______________ _______________ _______________ _______________ _______________ Who _______________ _______________ _______________ _______________ _______________ _______________ _______________ - What _______________ _______________ _______________ _______________ _______________ _______________ _______________ Where _______________ _______________ _______________ _______________ _______________ _______________ _______________ Who _______________ _______________ _______________ _______________ _______________ _______________ _______________ - Evening What _______________ _______________ _______________ _______________ _______________ _______________ _______________ Where _______________ _______________ _______________ _______________ _______________ _______________ _______________ Who _______________ _______________ _______________ _______________ _______________ _______________ _______________ - What _______________ _______________ _______________ _______________ _______________ _______________ _______________ Where _______________ _______________ _______________ _______________ _______________ _______________ _______________ Who _______________ _______________ _______________ _______________ _______________ _______________ _______________ - Comments _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ ———————————————————————————————————————————————————————————————————————————————————— PATIENT HEALTH QUESTIONNAIRE 9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer) 0 — Not at all 1 — Several days 2 — More than half the days 3 — Nearly every day 1. Little interest or pleasure indoing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or havinglittle energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 FOR OFFICE CODING _+_+_+_ = Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. ———————————————————————————————————————————————————————————————————————————————————— STEP 5 : STAYING WELL Well done on getting this far. You have now completed all the steps that can help you feel better and remain well. You have hopefully learned what works best for you and become aware that starting to do things again helps you keep on top of low mood and depression and can prevent any future dips in your mood. You may have rediscovered past activities you are enjoying again, or have discovered new ones. Perhaps you have found new freedom to do the things you always wanted to do. Either way to stay well it is important to keep up the good work and carry on doing the routine, pleasurable and necessary activities you have started to do again. Keeping an eye on your mood It is however perfectly normal to feel a little down at times. Everyone does and it will be no different for you! Next time you feel down therefore do not get too concerned too quickly. However it is worth keeping an eye on your mood just to ensure it does improve on its own. Developing a low mood alarm and activity toolkit To do this it is worth reminding yourself again about the main signs that may indicate your depression is returning. Think back to the time when you were last depressed. Then use the ‘Low Mood Alarm’ to write the main signs in each box that could indicate your low mood has returned. Also write in the activities that you felt really helped lift your mood. Even now you may have stopped doing some of these. This then becomes your personal alarm that your low mood may be returning and your personal activity toolkit to try and help lift your mood once again. My low mood alarm and activity toolkit Last time I was depressed I did the following things differently or stopped doing them altogether... ________________________ ________________________ ________________________ ________________________ Last time I was depressed the following unhelpful thoughts ran through my head... ________________________ ________________________ ________________________ ________________________ Last time I was depressed I felt the following physical symptoms... ________________________ ________________________ ________________________ ________________________ Last time I was depressed, doing the following activities really helped... ________________________ ________________________ ________________________ ________________________ Remember: Simply experiencing any of these symptoms for a short time will be perfectly normal. However if you find yourself experiencing them for a while and it is beginning to have an impact on your life again then you may need to do something about it. Using your Toolkit It will no doubt be distressing if you feel your low mood has returned. However if you notice this then the first thing to do is to try and start doing those activities again you felt really helped last time. It may be that working through ‘Get Active, Feel Good’ again could also be helpful. It worked last time so can do so again. And you can always make contact with your depression service if you feel you need extra support. Just by doing the routine, pleasurable and necessary activities you have started to do again and keeping structure in your life however there is every chance you will keep on top of your low mood. ABOUT THE AUTHORS Dr Paul Farrand is a Senior Lecturer within the Mood Disorders Centre and Director of Psychological Wellbeing Practitioner training within Clinical Education, Development and Research (CEDAR) at the University of Exeter. His main clinical and research interests are in the area of low intensity cognitive behavioural therapy (CBT), especially in a self-help format. Based upon his research and clinical practice he has developed a wide range of written self-help treatments for depression and anxiety. Professor Adrian Taylor specialises in developing and evaluating interventions and support for health behaviour change as a way of improving and regulating psychological well-being. As one of the Directors of Research in the College of Life and Environmental Sciences at the University of Exeter, he has led and supported many nationally and internationally renowned research studies. His work has featured in a variety of clinical guidelines for helping people to gain control over various health behaviours as well as mood. Dr Colin Greaves is a health psychologist and Senior Research Fellow at the University of Exeter Medical School. He has research expertise in developing and testing interventions to help people undertake lifestyle change. Based upon his research he has developed an intervention to help people with asthma manage their condition, several weight loss interventions and a self-help manual for people with heart failure. Dr Claire Pentecost is a Research Associate at the Mood Disorders Centre, University of Exeter. Her research experience is in designing and delivering programmes for lifestyle change for people with diabetes, depression and other long-term conditions. Claire’s most recent research looked at the reasons why some people do, and some people do not take up lifestyle change courses recommended by a GP. This trial is funded by the National Prevention Research Initiative (NPRI-4) comprising of the Medical Research Council and Partners: Alzheimer’s Research Trust Alzheimer’s Society Biotechnology and Biological Sciences Research Council British Heart Foundation Cancer Research UK Chief Scientist Office, Scottish Government Health Directorate Department of Health Diabetes UK Economic and Social Research Council Engineering and Physical Sciences Research Council Health and Social Care Research Division, Public Health Agency, Northern Ireland Medical Research Council Stroke Association Wellcome Trust Welsh Government World Cancer Research Fund Acknowledgement: This booklet is based on the behavioural activation model included within ‘Reach Out: National Programme Educator Materials to Support the Delivery of Training for Psychological Wellbeing Practitioners Delivering Low Intensity Interventions’ by Professor David Richards and Dr Mark Whyte. Copyright statement: c 2013. The right of Paul Farrand, Adrian Taylor, Colin Greaves and Claire Pentecost to be identified as the authors of this work has been asserted by them in accordance with the Copyright, Designs and Patent Act, 1998. All rights reserved. The booklet has been produced on the condition that it shall not, by way of trade or otherwise, be lent, sold, hired out or otherwise circulated in any form binding or cover other than that in which it is published and without a similar condition including this condition being imposed on the subsequent reader. Materials in this work may not be freely copied for any purpose. Research Statement: This booklet has been developed as part of a research grant awarded by the National Prevention Research Initiative http://www.mrc.ac.uk/NPRI/ ———————————————————————————————————————————————————————————————————————————————————— PATIENT HEALTH QUESTIONNAIRE 9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer) 0 — Not at all 1 — Several days 2 — More than half the days 3 — Nearly every day 1. Little interest or pleasure indoing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or havinglittle energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 FOR OFFICE CODING _+_+_+_ = Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. ———————————————————————————————————————————————————————————————————————————————————— Dear GP, I am writing in relation to patient: NAME: Mr XXXX XXXX XXXX DOB: XX-XXX-XXXX NHS#: XXX-XXX-XXXX I assessed Mr XXXXX on the 21/07 at 380 Streatham High Road following a referral to our service. A copy of the full assessment will be forwarded to you in due course. I have discussed Mr XXXXX's case with my team in our MDT meeting and it has been recommended that Mr XXXXX re-initiate Sertraline as he reports that he did benefit from this previously. Following a period of stabilisation it is felt that Mr Castillo would then benefit from long-term therapy and I intend to complete a referral for this in due course. I have attached the plan below moving forward. PLAN: GP to kindly prescribe Sertraline 50mg OM. Next face to face review has been scheduled for 11/08 @ 11:00am. Please do not hesitate to contact me should you have any queries. Kind regards Denis Lenta-Odedra Community Practitioner Lambeth South West Short Term Support Service South London and Maudsley NHS Foundation Trust 380 Streatham High Road, London, SW16 6HP Office/Duty: 020 3228 8100 Mobile: 07468 727857 Website: https://lambethtogether.net/living-well-network-alliance/get-help/lambeth-single-point-of-access/ ———————————————————————————————————————————————————————————————————————————————————— Hi Can someone please confirm the below prescription has been received? I’ve been told it was sent to the wrong email address. I believe I need this medication. I’ve tried to follow up over the phone but I’ve just been on hold for over 20mins. Thanks XXXXXX ———————————————————————————————————————————————————————————————————————————————————— Hi Could you please confirm this email has been received and it's being looked into? Thanks XXXXXX ———————————————————————————————————————————————————————————————————————————————————— Hi XXXXXX, I am just seeing this e-mail on my return from leave today. Has this issue been resolved? I can follow this up for you if not. Kind regards Denis Lenta-Odedra Community Practitioner Lambeth South West Short Term Support Service South London and Maudsley NHS Foundation Trust 380 Streatham High Road, London, SW16 6HP Office/Duty: 020 3228 8100 Mobile: 07468 727857 Website: https://lambethtogether.net/living-well-network-alliance/get-help/lambeth-single-point-of-access/ ———————————————————————————————————————————————————————————————————————————————————— Hi XXXXXXX, Please find enclosed the medication leaflet for Mirtazapine. If you still want to go ahead, I will write to your GP and copy you in. Let me know your thoughts. Kind regards Denis Lenta-Odedra Community Practitioner Lambeth South West Short Term Support Service South London and Maudsley NHS Foundation Trust 380 Streatham High Road, London, SW16 6HP Office/Duty: 020 3228 8100 Mobile: 07468 727857 Website: https://lambethtogether.net/living-well-network-alliance/get-help/lambeth-single-point-of-access/ ———————————————————————————————————————————————————————————————————————————————————— Package leaflet: Information for the user Mirtazapine 15, 30 & 45 mg tablets (Mirtazapine) Read all of this leaflet carefully before you start taking this medicine because it contains important information for you. - Keep this leaflet. You may need to read it again. - If you have any further questions, ask your doctor or pharmacist. - This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours. - If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. See section 4. What is in this leaflet 1. What Mirtazapine tablet is and what it is used for 2. What you need to know before you take Mirtazapine tablets 3. How to take Mirtazapine tablets 4. Possible side effects 5. How to store Mirtazapine tablets 6. Contents of the pack and other information 1. What Mirtazapine tablet is and what it is used for Mirtazapine is one of a group of medicines called antidepressants. Mirtazapine tablets are used to treat depressive illness in adults. Mirtazapine will take 1 to 2 weeks before it starts working. After 2 to 4 weeks you may start feeling better. You must talk to your doctor if you do not feel better or if you feel worse after 2 to 4 weeks. More information is in section 3 heading “When can you expect to start feeling better”. 2. What you need to know before you take Mirtazapine tablets Do not take Mirtazapine tablets: • if you are allergic (hypersensitive) to mirtazapine or any of the other ingredients of this medicine (listed in section 6). If so, you must talk to your doctor as soon as you can before taking Mirtazapine tablets. • if you are taking or have recently taken (within the last two weeks) medicines called monoamine oxidase inhibitors (MAO-Is). Warnings and precautions Talk to your doctor or pharmacist before taking Mirtazapine tablets. Children and adolescents Mirtazapine should normally not be used for children and adolescents under 18 years because efficacy was not demonstrated. Also, you should know that patients under 18 have an increased risk of side-effects such as suicide attempt, suicidal thoughts and hostility (predominantly aggression, oppositional behaviour and anger) when they take this class of medicines. Despite this, your doctor may prescribe Mirtazapine tablets for patients under 18 because he/she decides that this is in their best interests. If your doctor has prescribed Mirtazapine tablets for a patient under 18 and you want to discuss this, please go back to your doctor. You should inform your doctor if any of the symptoms listed above develop or worsen when patients under 18 are taking Mirtazapine tablets. Also, the long-term safety effects concerning growth, maturation and cognitive and behavioural development of Mirtazapine in this age group have not yet been demonstrated. In addition, significant weight gain has been observed in this age category more often when treated with Mirtazapine compared with adults. Thoughts of suicide and worsening of your depression If you are depressed you can sometimes have thoughts of harming or killing yourself. These may be increased when first starting antidepressants, since these medicines all take time to work, usually about two weeks but sometimes longer. You may be more likely to think like this: • if you have previously had thoughts about killing or harming yourself. • if you are a young adult. Information from clinical trials has shown an increased risk of suicidal behaviour in adults aged less than 25 years with psychiatric conditions who were treated with an antidepressant. → If you have thoughts of harming or killing yourself at any time, contact your doctor or go to a hospital straight away. You may find it helpful to tell a relative or close friend that you are depressed, and ask them to read this leaflet. You might ask them to tell you if they think your depression is getting worse, or if they are worried about changes in your behaviour. Also take special care with Mirtazapine • if you have, or have ever had one of the following conditions. → Tell your doctor about these conditions before taking Mirtazapine, if not done previously. - seizures (epilepsy). If you develop seizures or your seizures become more frequent, stop taking Mirtazapine and contact your doctor immediately; - liver disease, including jaundice. If jaundice occurs, stop taking Mirtazapine and contact your doctor immediately; - kidney disease; - heart disease, or low blood pressure; - schizophrenia. If psychotic symptoms, such as paranoid thoughts become more frequent or severe, contact your doctor straightaway; - manic depression (alternating periods of feeling elated/overactivity and depressed mood). If you start feeling elated or over-excited, stop taking Mirtazapine and contact your doctor immediately; - diabetes (you may need to adjust your dose of insulin or other antidiabetic medicines); - eye disease, such as increased pressure in the eye (glaucoma); - difficulty in passing water (urinating), which might be caused by an enlarged prostate. - certain kinds of heart conditions that may change your heart rhythm, a recent heart attack, heart failure, or take certain medicines that may affect the heart’s rhythm. • if you develop signs of infection such as inexplicable high fever, sore throat and mouth ulcers. → Stop taking Mirtazapine and consult your doctor immediately for a blood test. In rare cases these symptoms can be signs of disturbances in blood cell production in the bone marrow. While rare, these symptoms most commonly appear after 4-6 weeks of treatment. • if you are an elderly person. You could be more sensitive to the side-effects of antidepressants. Other medicines and Mirtazapine tablets Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines. Do not take Mirtazapine in combination with: • monoamine oxidase inhibitors (MAO inhibitors). Also, do not take Mirtazapine during the two weeks after you have stopped taking MAO inhibitors. If you stop taking Mirtazapine, do not take MAO inhibitors during the next two weeks either. Examples of MAO inhibitors are moclobemide, tranylcypromine (both are antidepressants) and selegiline (used for Parkinson’s disease). Take care when taking Mirtazapine in combination with: • antidepressants such as SSRIs, venlafaxine and L-tryptophan, or triptans (used to treat migraine), tramadol (a pain-killer), linezolid (an antibiotic), lithium (used to treat some psychiatric conditions), methylene blue (used to treat high levels of methemoglobin in the blood) and St. John’s Wort – Hypericum perforatum preparations (a herbal remedy for depression). In very rare cases Mirtazapine alone or the combination of Mirtazapine with these medicines, can lead to a so-called serotonin syndrome. Some of the symptoms of this syndrome are: inexplicable fever, sweating, increased heart rate, diarrhoea, (uncontrollable) muscle contractions, shivering, overactive reflexes, restlessness, mood changes, and unconsciousness. If you get a combination of these symptoms, talk to your doctor immediately. • the antidepressant nefazodone. It can increase the amount of Mirtazapine in your blood. Inform your doctor if you are using this medicine. It might be needed to lower the dose of Mirtazapine, or when use of nefazodone is stopped, to increase the dose of Mirtazapine again. • medicines for anxiety or insomnia such as benzodiazepines; medicines for schizophrenia such as olanzapine; medicines for allergies such as cetirizine; medicines for severe pain such as morphine. In combination with these medicines Mirtazapine can increase the drowsiness caused by these medicines. • medicines for infections; medicines for bacterial infections (such as erythromycin); medicines for fungal infections (such as ketoconazole) and medicines for HIV/AIDS (such as HIV-protease inhibitors) and drugs for stomach ulcers (such as cimetidine). In combination with Mirtazapine these medicines can increase the amount of Mirtazapine in your blood. Inform your doctor if you are using these medicines. It might be needed to lower the dose of Mirtazapine, or when these medicines are stopped, to increase the dose of Mirtazapine again. • medicines for epilepsy such as carbamazepine and phenytoin; medicines for tuberculosis such as rifampicin. In combination with Mirtazapine these medicines can reduce the amount of Mirtazapine in your blood. Inform your doctor if you are using these medicines. It might be needed to increase the dose of Mirtazapine, or when these medicines are stopped to lower the dose of Mirtazapine again. • medicines to prevent blood clotting such as warfarin. Mirtazapine can increase the effects of warfarin on the blood. Inform your doctor if you are using this medicine. In case of combination it is advised that a doctor monitors your blood carefully. • medicines that may affect the heart’s rhythm such as certain antibiotics and some anti psychotics. Mirtazapine tablets with food and alcohol You may get drowsy if you drink alcohol while you are taking Mirtazapine. You are advised not to drink any alcohol. You can take Mirtazapine tablets with or without food. Pregnancy and breast-feeding If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor or pharmacist for advice before taking this medicine. Limited experience with Mirtazapine administration to pregnant women does not indicate an increased risk. However, caution should be exercised when used during pregnancy. If you use Mirtazapine tablets until, or shortly before birth, your baby should be supervised for possible adverse effects. Make sure your midwife and/or doctor knows you are on Mirtazapine tablets. When taken during pregnancy, similar drugs (SSRIs) may increase the risk of a serious condition in babies, called persistent pulmonary hypertension of the newborn (PPHN), making the baby breathe faster and appear bluish. These symptoms usually begin during the first 24 hours after the baby is born. If this happens to your baby you should contact your midwife and/or doctor immediately. Driving and using machines Mirtazapine tablets can affect your concentration or alertness. Make sure these abilities are not affected before you drive or operate machinery. If your doctor has prescribed Mirtazapine tablets for a patient under 18 years make sure the concentration and alertness is not affected before participation in traffic (e.g. on bicycle). Mirtazapine tablets contain Lactose If you have been told by your doctor that you have an intolerance to some sugars, contact your doctor before taking this medicinal product. 3. How to take Mirtazapine tablets Always take this medicine exactly as your doctor or pharmacist has told you. Check with your doctor or pharmacist if you are not sure. How much to take The recommended starting dose is 15 or 30 mg every day. Your doctor may advise you to increase your dose after a few days to the amount that is best for you (between 15 and 45 mg per day). The dose is usually the same for all ages. However, if you are an elderly person or if you have renal or liver disease, your doctor may adapt the dose. When to take Mirtazapine tablets → Take Mirtazapine tablets at the same time each day. It is best to take Mirtazapine tablets as a single dose before you go to bed. However your doctor may suggest to split your dose of Mirtazapine tablets – once in the morning and once at night-time before you go to bed. The higher dose should be taken before you go to bed. Take your tablets orally. Swallow your prescribed dose of Mirtazapine tablets without chewing, with some water or juice. When can you expect to start feeling better Usually Mirtazapine tablets will start working after 1 to 2 weeks and after 2 to 4 weeks you may start to feel better. It is important that, during the first few weeks of the treatment, you talk with your doctor about the effects of Mirtazapine tablets: → 2 to 4 weeks after you have started taking Mirtazapine tablets, talk to your doctor about how this medicine has affected you. If you still don’t feel better, your doctor may prescribe a higher dose. In that case, talk to your doctor again after another 2 to 4 weeks. Usually you will need to take Mirtazapine tablets until your symptoms of depression have disappeared for 4 to 6 months. If you take more Mirtazapine tablets than you should → If you or someone else have taken too much Mirtazapine tablets, call a doctor straight away. The most likely signs of an overdose of Mirtazapine tablets (without other medicines or alcohol) are drowsiness, disorientation and increased heart rate. The symptoms of a possible overdose may include changes to your heart rhythm (fast, irregular heartbeat) and/or fainting which could be symptoms of a life-threatening condition known as Torsade de Pointes. If you forget to take Mirtazapine tablets If you are supposed to take your dose once a day • Do not take a double dose to make up for a forgotten dose. Take your next dose at the normal time. If you are supposed to take your dose twice a day • if you have forgotten to take your morning dose, simply take it together with your evening dose. • if you have forgotten to take your evening dose, do not take it with the next morning dose; just skip it and continue with your normal morning and evening doses. • if you have forgotten to take both doses, do not attempt to make up for the missed doses. Skip both doses and continue the next day with your normal morning and evening doses. If you stop taking Mirtazapine tablets → Only stop taking Mirtazapine tablets in consultation with your doctor. If you stop too early, your depression might come back. Once you are feeling better, talk to your doctor. Your doctor will decide when treatment can be stopped. Do not suddenly stop taking Mirtazapine tablets, even when your depression has lifted. If you suddenly stop taking Mirtazapine tablets you may feel sick, dizzy, agitated or anxious, and have headaches. These symptoms can be avoided by stopping gradually. Your doctor will tell you how to decrease the dose gradually. If you have any further questions on the use of this medicine, ask your doctor or pharmacist. 4. Possible side effects Like all medicines, this medicine can cause side effects, although not everybody gets them. If you experience any of the following serious side effects, stop taking mirtazapine and tell your doctor immediately. Uncommon (may affect up to 1 in 100 people): • feeling elated or emotionally ‘high’ (mania) Rare (may affect up to 1 in 1,000 people): • yellow colouring of eyes or skin; this may suggest disturbance in liver function (jaundice) Not known (frequency cannot be estimated from the available data): • signs of infection such as sudden unexplainable high fever, sore throat and mouth ulcers (agranulocytosis). In rare cases mirtazapine can cause disturbances in the production of blood cells (bone marrow depression). Some people become less resistant to infection because mirtazapine can cause a temporary shortage of white blood cells (granulocytopenia). In rare cases mirtazapine can also cause a shortage of red and white blood cells, as well as blood platelets (aplastic anemia), a shortage of blood platelets (thrombocytopenia) or an increase in the number of white blood cells (eosinophilia). • epileptic attack (convulsions) • a combination of symptoms such as inexplicable fever, sweating, increased heart rate, diarrhoea, (uncontrollable) muscle contractions, shivering, overactive reflexes, restlessness, mood changes, unconsciousness and increased salivation. In very rare cases these can be signs of serotonin syndrome. • thoughts of harming or killing yourself • severe skin reactions (Stevens-Johnson Syndrome, toxic epidermal necrolysis) Other possible side effects with mirtazapine are: Very common (may affect more than 1 in 10 people): • increase in appetite and weight gain • drowsiness or sleepiness • headache • dry mouth Common (may affect up to 1 in 10 people): • constipation • lethargy • dizziness • shakiness or tremor • nausea • diarrhoea • vomiting • rash or skin eruptions (exanthema) • pain in your joints (arthralgia) or muscles (myalgia) • back pain • feeling dizzy or faint when you stand up suddenly (orthostatic hypotension) • swelling (typically in ankles or feet) caused by fluid retention (oedema) • tiredness • vivid dreams • confusion • feeling anxious • sleeping problems Uncommon (may affect up to 1 in 100 people): • abnormal sensation in the skin e.g. burning, stinging, tickling or tingling (paraesthesia) • restless legs • fainting (syncope) • sensations of numbness in the mouth (oral hypoaesthesia) • low blood pressure • nightmares • feeling agitated • hallucinations • urge to move Rare (may affect up to 1 in 1,000 people): • muscle twitching or contractions (myoclonus) • aggression • abdominal pain and nausea; this may suggest inflammation of the pancreas (pancreatitis) Not known (frequency cannot be estimated from the available data): • abnormal sensations in the mouth (oral paraesthesia) • swelling in the mouth (mouth oedema), increase in saliva secretion or watery mouth • swelling throughout the body (generalized oedema) • localized swelling • hyponatraemia • inappropriate anti-diuretic hormone secretion • speech disorder • sleepwalking (somnambulism) • blisters of the skin (dermatitis bullous) • Skin rash, which may blister, and looks like small targets (central dark spots surrounded by a paler area, with a dark ring around the edge) called erythema multiforme • Increased creatine kinase blood levels • difficulty in passing urine (urinary retention) • muscle pain, stiffness and/or weakness, darkening or discolouration of the urine (rhabdomyolysis) Additional side effects in children and adolescents In children under 18 years the following adverse events were observed commonly in clinical trials: significant weight gain, hives and increased blood triglycerides. Reporting of side effects If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via the Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard. By reporting side effects you can help provide more information on the safety of this medicine. 5. How to store Mirtazapine tablets Keep this medicine out of the sight and reach of children. This medicinal product does not require any special storage conditions. Store in the original package. Do not use this medicine after the expiry date, which is stated on the carton and the blister after EXP. The expiry date refers to the last day of that month. Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help to protect the environment. 6. Contents of the pack and other information What Mirtazapine tablet contains - The active substance is Mirtazapine. Each film coated tablet contains 15, 30 or 45 mg Mirtazapine. - The other ingredients are lactose monohydrate, maize starch, hydroxypropyl cellulose, low substituted hydroxypropyl cellulose, magnesium stearate (E470b), silica colloidal anhydrous, hypromellose (E464) and titanium dioxide (E 171). The 15 mg tablets also contain yellow iron oxide (E 172). The 30 mg tablets also contain yellow iron oxide (E172), red iron oxide (E172) and black iron oxide (E172). What Mirtazapine tablet looks like and contents of the pack Mirtazapine 15 mg tablets are yellow, biconvex, capsule shaped film coated tablets with a score line in between ‘0’ and ‘8’ debossed on one side and ‘A’ on other side. Mirtazapine 30 mg tablets are reddish brown, biconvex, capsule shaped film coated tablets with a score line in between ‘0’ and ‘9’ debossed on one side and ‘A’ other side. Mirtazapine 45 mg tablets are white, biconvex, capsule shaped film coated tablets debossed with ‘10’ on one side and ‘A’ on the other side. Mirtazapine 15, 30 and 45 mg tablets are available in PVC coated PVdC blister packs of 10/14/28/30/40/50/56/60/70/84/90/100/200/250/500 tablets. Not all packs may be marketed. Marketing Authorisation Holder and Manufacturer Marketing Authorisation Holder Milpharm Limited Ares Block Odyssey Business Park West End Road Ruislip HA4 6QD United Kingdom Manufacturer Milpharm Limited, Ares, Odyssey Business Park, West End Road, South Ruislip HA4 6QD, United Kingdom. or APL Swift Services (Malta) Limited HF26, Hal Far Industrial Estate, Hal Far, Birzebbugia, BBG 3000. Malta This leaflet was last revised in 07/2018. P1519905 ———————————————————————————————————————————————————————————————————————————————————— Hey Denis Thanks for forwarding me the information regarding Mirtazapine. I’ve read it and it looks like I’ll be feeling tired and sleepy over the first weeks, which is the main issue I’m having with Sertraline. If either way I’ll feel that way I was thinking about giving Sertraline another week, see how it goes. Happy to increase the dose if you reckon that’ll speed things up. When you get a spare sec do you mind calling me so we can discuss it over the phone? Thanks XXXXXXXX ———————————————————————————————————————————————————————————————————————————————————— Hi XXXXXXXX, Good to see you earlier. Just confirming our next appointment for 17/09 @ 2pm at 380 Streatham High Road. As requested, if you could try to keep a mood diary for the next couple of weeks to note down any pertinent changes or events that you might notice has provoked a response in your mood - this would be useful. I have attached a "Mood Diary" template if this is helpful. Additionally, as you suggested, possibly contacting your GP to rule-out any medical causes for your tiredness in the day would be useful. See you in a couple of weeks. Denis Denis Lenta-Odedra Community Practitioner Lambeth South West Short Term Support Service South London and Maudsley NHS Foundation Trust 380 Streatham High Road, London, SW16 6HP Office/Duty: 020 3228 8100 Mobile: 07468 727857 Website: https://lambethtogether.net/living-well-network-alliance/get-help/lambeth-single-point-of-access/ ———————————————————————————————————————————————————————————————————————————————————— Mood Diary Day & Time Mood / Emotion Comments Rate intensity of emotion Example: What was happening, where, who with? 0 – 100 % What went through your mind (thoughts, images)? What were you doing just before and / or after you felt this way? _______________ ________________________________ _________________________________________________________________ _______________ ________________________________ _________________________________________________________________ _______________ ________________________________ _________________________________________________________________ _______________ ________________________________ _________________________________________________________________ _______________ ________________________________ _________________________________________________________________ _______________ ________________________________ _________________________________________________________________ _______________ ________________________________ _________________________________________________________________ www.getselfhelp.co.uk £ Carol Vivyan 2010. Permission to use for therapy purposes. www.get.gg ———————————————————————————————————————————————————————————————————————————————————— Dear GP, I am writing in relation to patient: NAME: XXXXX XXXXX XXXXX DOB: XX-XXX-XXXX NHS#: XXX-XXX-XXXX I reviewed Mr Cruz over the phone today and he reports that he continues to experience some adverse side effects from his newly initiated Sertraline included feeling of lethargy, overwhelming fear and continued low mood. However, he acknowledges that he has benefited from this medication in the past and would like to continue with the plan to increase the medication to more of a therapeutic dose in the event that he starts to tolerate and benefit from its effects. We have agreed to trial this increase and review things in a couple of weeks. I have attached the plan moving forward. PLAN: GP to kindly increase Sertraline to 100mg OD. I will review Mr XXXX's progress at 380 SHR on Thursday 3rd September at 2pm. Please do not hesitate to contact me should you have any queries. Kind regards Denis Lenta-Odedra Community Practitioner Lambeth South West Short Term Support Service South London and Maudsley NHS Foundation Trust 380 Streatham High Road, London, SW16 6HP Office/Duty: 020 3228 8100 Mobile: 07468 727857 Website: https://lambethtogether.net/living-well-network-alliance/get-help/lambeth-single-point-of-access/ ———————————————————————————————————————————————————————————————————————————————————— Hi there I would like to book an appointment with my GP. NAME: XXXXX XXXXX XXXXX DOB: XX-XXX-XXXX NHS#: XXX-XXX-XXXX Please let me know which day and time is available. Thanks XXXXX ———————————————————————————————————————————————————————————————————————————————————— Please give the reason you would like to speak to a Dr. ———————————————————————————————————————————————————————————————————————————————————— Dear GP, I am writing in relation to patient: NAME: XXXXX XXXXX XXXXX DOB: XX-XXX-XXXX NHS#: XXX-XXX-XXXX I reviewed Mr XXXX yesterday afternoon and have discussed his case with Dr Kyratsous (Consultant Psychiatrist). It has been agreed with Mr XXXX to increase his Sertraline to 150mg OD and I will review again in a few weeks. PLAN: GP to kindly increase Sertraline to 150mg OD. I will review Mr XXXX's progress at his next appointment on 22/10 @ 2pm. Please do not hesitate to contact me should you have any queries. Kind regards Denis Lenta-Odedra Community Practitioner Lambeth South West Short Term Support Service South London and Maudsley NHS Foundation Trust 380 Streatham High Road, London, SW16 6HP Office/Duty: 020 3228 8100 Mobile: 07468 727857 Website: https://lambethtogether.net/living-well-network-alliance/get-help/lambeth-single-point-of-access/ ———————————————————————————————————————————————————————————————————————————————————— Dear XXXXX, Good to see you yesterday. As promised, I have spoken with Michalis who has agreed to increase your Sertraline to 150mg OD. It should hopefully help to lift your mood, but as discussed yesterday, the reason for the recent dip is most-likely related to acute stressors. I am hopeful however, that you should benefit from this. I will write to your GP this afternoon to request the increase, and will copy you in. Also, I have attached the links for low-cost therapy options that you can access whilst we await to hear whether you have been accepted for therapy with IPTT. Unfortunately, I am unable to recommend one particular provider who it would be worth giving them a call. I hope you are able to access your GP surgery for blood tests to rule-out any physical health causes to your tiredness. As discussed, I will be on annual leave w/c 12/10 but have booked an appointment in my diary to see you when I return on Thursday 22nd October at 2pm. Any concerns or queries in the next week, please get in contact with me. During my annual leave you can contact the duty team on: 020 3228 8100. Kind regards Denis Lenta-Odedra Community Practitioner Lambeth South West Short Term Support Service South London and Maudsley NHS Foundation Trust 380 Streatham High Road, London, SW16 6HP Office/Duty: 020 3228 8100 Mobile: 07468 727857 Website: https://lambethtogether.net/living-well-network-alliance/get-help/lambeth-single-point-of-access/ ———————————————————————————————————————————————————————————————————————————————————— External Counselling and Therapy ARBOURS ASSOCIATION • The Arbours Association is an internationally renowned registered charity with 40 years’ experience providing psychotherapeutic support. • Offers low fee Psychoanalytic Psychotherapy in North & South London, £5 - £15 per session. • All therapists are registered with UKCP and can be searched via online search engine. Tel: 020 8340 7646 Email: info@arboursassociation.org or online referral form Website: www.arboursassociation.org -- THE ASSOCIATION FOR PSYCHOTHERAPY IN EAST LONDON (APEL) • APEL is a group of psychotherapists offering individual and group psychotherapy in East London and Essex. • The APEL Charitable Trust makes grants to individuals in East London or Essex to help pay for private psychotherapy. The number of grants is very limited. Tel: 020 8556 5089 Email: via online enquiry form Website: www.apel.org.uk -- THE ASSOCIATION FOR GROUP AND INDIVIDUAL PSYCHOTHERAPY (AGIP) • AGIP provides psychoanalytic psychotherapy and training. • AGIP’s Fairbridge Clinic offers twice weekly psychotherapy to those on low incomes with fees ranging from £8 to £18 per session. • Initial assessment costs £35. • Twice weekly therapy (sometimes weekly available) for minimum of 2 years. • Appointments usually at the clinic in Archway. N19 3EW Tel: 020 7272 7013 Email: office@agip.org.uk or online referral form Website: www.agip.org.uk -- THE BOWLBY CENTRE • A training and referral organisation specialising in attachment-based psychotherapy. • Fees £50 - £75 on average per session. Some therapists offer sliding scale of fees according to income. • Therapists across London. • The Blues Project for people on low income who can commit to twice a week therapy for at least 2 years. Assessment £25, ongoing sessions £6.50. Address: 147 Commercial St, London E1 6BJ Tel: 0207 247 1102 (referrals) Email: admin@thebowlbycentre.org.uk Website: www.thebowlbycentre.org.uk -- THE BRANDON CENTRE • Free counselling and psychotherapy for 12 to 21 year olds. • Only available for young people in Boroughs of Islington and Camden. • Also run a clinic called the Drum for young people who live/study in Islington. Appts on Thurs and Fri. Address: 26 Prince of Wales Road, NW5 3LG Drum address: 167 Whitecross St, EC1Y 8JT Tel: 020 7267 4792 Email: counselling@brandoncentre.org.uk Website: www.brandon-centre.org.uk -- THE BRITISH ASSOCIATION FOR BEHAVIOURAL AND COGNITIVE THERAPIES (BABCP) • BABCP is the lead organisation for CBT in the UK. A registered charity with many thousands of members, BABCP aims to promote the practice, theory and development of CBT. • BABCP is the only organisation which accredits CBT therapists. • You can search online for accredited BABCP CBT and AREBT therapists. Tel: 0161 705 4304 Email: babcp@babcp.com Website: www.babcp.com and www.cbtregisteruk.com -- THE BRITISH ASSOCIATION FOR COUNSELLING AND PSYCHOTHERAPY (BACP) • A membership organisation that sets standards for therapeutic practice and provides information for therapists, clients of therapy, and the general public. • The BACP’s interactive website ‘It’s good to talk’ is designed to inform the public about counselling. • You can search online for a counsellor and call to speak to someone about any queries or concerns you have about counselling. Tel: 01455 88 33 00 Email: bacp@bacp.co.uk Website: www.bacp.co.uk and www.itsgoodtotalk.org.uk -- THE FREE PSYCHOTHERAPY NETWORK • Website listing free / low cost services for ongoing psychological therapies. Website: freepsychotherapynetwork.com -- BRITISH PSYCHOTHERAPY FOUNDATION (BPF) • A training, referral and membership organisation for Jungian analytic and psychoanalytic psychotherapy. • Therapists across London and surrounds. • Reduced Fee Scheme for those on low incomes prepared to attend 3-4 times weekly for at least two years. Current vacancies and more info about referrals on website. Address: 37 Mapesbury Road, NW2 4HJ Tel: 020 8452 9823 Website: www.britishpsychotherapyfoundation.org.uk/ -- COMMUNITY COUNSELLING – EAST HAM • A group of committed, professionally qualified counsellors operating as a registered charity. • Aim is to provide a low-cost high-quality service to those clients who may not be able to access counselling due to cost. • Offer short-term and open-ended counselling • minimum charge is £6.00 per session Address: St Bart’s Community Centre at 292b Barking Road, East Ham, London E6 3BA Tel: 07547 893 700 or 020 8524 9711 Email: online email Website: http://www.communitycounselling.org.uk -- COMMUNITY PSYCHOTHERAPY NETWORK • A social enterprise in Bethnal Green • Offers group-based psychological work, with once weekly and twice weekly groups, and psychodynamic psychotherapy for individuals, couples and families. • Aim is to provide a low-cost high-quality service to those clients who may not be able to access counselling due to cost. • Offer open-ended counselling with a sliding scale of fees. Minimum charge is £5, low-fee £15-£25, normal fee £25-£60. Address: 15/b Old Ford Road, Bethnal Green, London, E29PL Tel: 020 3539 9647 and 07403 603 615 Email: info@communitypsychotherapy.org.uk Website: http://communitypsychotherapy.org.uk/ (currently no waiting list – 24/03/16) -- CITY AND HACKNEY PRIMARY CARE PSYCHOTHERAPY CONSULTATION SERVICE • An NHS service for people with emotional or psychological problems who are struggling to cope with the support they are getting from their GP or other mental health services. • For people who are registered with a City and Hackney GP. • Talk to your GP to access the service, referral is only via your GP. Website: www.tavistockandportman.nhs.uk/cityhackneyservice -- COUNSELLING DIRECTORY • A database of counsellors and psychotherapists working in private practice with information on their training and experience, fees and contact details. Website: www.counselling-directory.org.uk -- CROSSROADS • Affordable counselling to residents of Tower Hamlets who have enduring emotional and mental health difficulties. • Sliding scale of fees. • Waiting list is often quite long. • Crossroads is founded on Christian faith but works with people from all faiths. Address: 144 Roman Road, London E2 0RY Tel: 020 8981 8388 Website: www.crossroadscounselling.org -- GUILD OF PSYCHOTHERAPISTS • Professional and training organisation for psychoanalytic psychotherapists. • Referral service for private psychoanalytic psychotherapy, across London and surrounds. • Speak to referral coordinator, Katie Grey for E. London: assessment over phone, unless cause for concern, then face-to-face assessment. • Reduced fee clinic for people on low income living in Southwark, Lambeth and Lewisham. £25 consultation, sliding scale fees, min £5 per session. Negotiated with therapists. Weekly/twice weekly up to 2 years. Address: 47 Nelson Square, Blackfriars Road, London SE1 0QA Tel: 020 7401 3370/020 8471 8016 (Katie Grey) Email: admin@guildofpsychotherapists.org.uk Website: www.guildofpsychotherapists.org.uk -- IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES (IAPT) • The IAPT programme provides therapeutic treatment via the NHS for people suffering from depression and anxiety. • Majority of London IAPT services are selfreferral so you can make an appt without seeing a GP first. For more info see the website. Website: overall service www.iapt.nhs.uk/services/services/london-nhsiapt-services Newham https://www.newhamtalkingtherapies.nhs.uk/ Tower Hamlets http://www.compasswellbeing.co.uk/ Hackney http://www.cityandhackneytalkingtherapy.nhs.uk/ -- INNER CITY CENTRE • A group of around 50 psychoanalytic psychotherapists providing therapy in the City and throughout London. • Sliding scale of fees according to income – from £15 per session. • Sessions weekly or more frequently. • Open-ended and brief therapy. • Also group and couple therapy. Address: 76 Wentworth Street London E1 7SA Tel: 020 7274 1589 Email: referrals@icclondon.org.uk Website: www.icclondon.org.uk -- THE KOAN PRACTICE • A group practice of therapists. • Long and short term therapy, couples therapy and CBT. • Appointments available day, evenings and weekends. • Fees according to income - £20 plus 1/1000th of your annual income. • Students and low waged £10 - £15 per session. • Online/email application form. Address: 10 Cobb Street, London E1 7LB and 19 Wentworth Street London E1 7TB Email: mail@psychotherapy.me Website: www.london-counsellingpsychotherapy.co.uk -- MANOR HOUSE CENTRE FOR PSYCHOTHERAPY AND COUNSELLING • Training institute that offers low cost therapy with counsellors who are senior trainees or experienced graduates. • Appts in Finchley or Barnet area. • Offer open-ended psychodynamic counselling. • Assessment £30 (if employed) or £10 (unemployed), ongoing sessions from £10 according to income. Address: 80 East End Road, Finchley, N2 2SY Tel: 020 8371 0180 Email: admin@manorhousecentre.org.uk Website: www.manorhousecentre.org.uk/counsellingservice.php -- THE METANOIA INSTITUTE • The Metanoia is a training institute that offers low cost therapy with counsellors and psychotherapists who are in training. • Appts in Ealing, evening sessions available. • Free assessment, up to six months of weekly sessions available. • Sessions cost between £5 to £25 based on income. Address: 13 North Common Road, Ealing, London W5 2QB Tel: 0208 832 3080 Email: ciara.wild@metanoia.ac.uk Website: www.metanoia.ac.uk -- MIND IN CITY AND HACKNEY • City and Hackney Mind provide a wide range of services including counselling to people who live and work in Hackney and the City. • Individual counselling, specialist trauma counselling and groups in Mindfulness Based Cognitive Therapy and Anger Management. • You may be asked for a contribution on a sliding scale basis. Address: 8-10 Tudor Road, Hackney E9 7SN Tel: 0208 525 2318 Email: services@cityandhackneymind.org.uk Website: www.cityandhackneymind.org.uk -- MIND IN ISLINGTON • Islington Mind provides counselling of up to 20 weeks to all residents of Islington. • There is a fee, although this is lower if you are receiving benefits or on a low income. Address: Unit 4, Archway Business Centre, 19-23 Wedmore Street, N19 4RU Tel: 020 3301 9850 Website: www.islingtonmind.org.uk -- MIND in TOWER HAMLETS • Mind in Tower Hamlets provides counselling to residents of Tower Hamlets. • Individual counselling (8-12 sessions), art and music therapy. • Sliding scale of fees £5-15. • Self-referral or via GP. Address: Open House, 13 Whitethorn St, E3 4DA Tel: 020 7510 1081/4247 Website: www.mithn.org.uk -- NAFSIYAT INTER-CULTURAL CENTRE • Nafsiyat offers short-term intercultural therapy to people from diverse backgrounds who live in Islington, Enfield, Camden and Haringey. We provide therapy in 24 languages. • Intercultural therapy as practised at Nafsiyat is a method of working therapeutically with the individual experience of patients, 'taking into account the whole being of the patient. Address: Unit 4, Lysander Mews Lysander Grove London N19 3QP Tel: 020 7263 6947 Website: http://www.nafsiyat.org.uk/ -- OFF CENTRE • Off Centre offers free counselling, art therapy and drama therapy for young people aged between 11 and 25 who live, work or study in Hackney. • Self-referrals (in person, by phone or via online enquiry form) or referrals from professionals. • Usually offer counselling up to 12 weeks. Address: 25-27 Hackney Grove, E8 3NR Tel: 020 8986 4016 Website: www.offcentre.org.uk -- TAVISTOCK CLINIC YOUNG PEOPLES CONSULTATION SERVICE (YPCS) • Offers free and confidential consultation within the NHS to anyone who has a personal or emotional problem. There can be up to four meetings of about an hour each. • Young people and adults 16-30 years. • London boroughs: Islington, Camden, Fulham, Hammersmith (GP address, not home address) • Only accepts self-referral. Address: Tavistock Centre, 120 Belsize Lane, London NW3 5BA Tel: 020 8938 2337 (Mon-Thu 10am-6pm) Email: atyps@tavi-port.nhs.uk Website: www.tavi-port.org -- THE SITE FOR CONTEMPORARY PSYCHOANALYSIS • The SITE is a training organisation which offers psychoanalysis at rates which are accessible for a range of incomes, including students and the unemployed. Address: 35 Manor Road, Herts EN6 1DQ Tel: 07980 865 040 Email: siteclinic@hotmail.com Website: www.the-site.org.uk -- STEP FORWARD • Free counselling and advice for young people aged 11-25 • Available to anyone in London, not borough specific. • Open ended counselling available up to a year. • Assessments offered within 2 weeks. • LGBTQ regular weekly personal development group- young people can contact solyma@step-forward.org for more information Address: 234 Bethnal Green Road, E2 0AA Tel: 020 7739 3082 Email: info@stepforward-web.org Website: www.stepforward-web.org -- WATERLOO COMMUNITY COUNSELLING • Low fee counselling service from £10 per session for anyone in London. • Counselling up to 18 weeks. Address: Barley Mow Clinic, Greet House, Frazier St, SE1 7BD Tel: 020 7928 3462 Email: info@waterloocc.co.uk Website: www.waterloocc.co.uk -- WOMEN’S THERAPY CENTRE • The Women's Therapy Centre provides group and individual psychoanalytic psychotherapy for women by women. • Committed to providing therapy to women who traditionally do not have equal access to psychotherapy. • Therapy available to: all refugee and asylum seeking women across London and also women aged 18-25 living in the following boroughs - Barnet, Brent, Camden, City of London, Ealing, Hammersmith & Fulham, Harrow, Kensington & Chelsea or Westminster • Also women who live in Islington and are Black, Asian or Minority Ethnic and/or have experienced childhood sexual abuse or domestic violence can access therapy through the Accept Consortium. • Sliding scale of fees - £5 min. • Self-referrals. • Also offers private practice referral service. Address: 10 Manor Gardens, N7 6JS Tel: 020 7263 6200 Email: appointments@womenstherapycentre.co.uk Website: www.womenstherapycentre.co.uk and www.accept-consortium.org.uk -- WPF THERAPY The WPF is a training institute that provides a range of therapies: - Long-term and short-term psychodynamic counselling - CBT - DIT - Group therapy • Registration fee is £25 and assessment session costs between £45 and £60. Ongoing sessions from £30 minimum. • Low cost clinic for full-time students and the unemployed - £20 per session (set appt times 8am, 9am and 10am Mon-Fri and all day Saturday). Address: 23 Magdalen Street, SE1 2EN Tel: 020 7378 2000 Email: reception@wpf.org.uk Website: www.wpf.org.uk -- YOUNG PERSONS’ THERAPY GROUP • A weekly analytic psychotherapy group for young people (20 - 30ish). • Group of 4-8 members run by group analyst Nick Barwick. • Wednesdays 6 - 7.30pm, £15 per session. • Free one-to-one meeting available to discuss things further. Address: The Guildhall School of Music and Drama, Barbican EC2 Tel: 020 7382 7219 Email: nickbarwick@ntlworld.com Website: www.analyticpractice.co.uk -- THERAPEUTIC GROUPS Association for Group and Individual Psychotherapy 1, Fairbridge Road, London N19 3EW Tel: 020-7272-7013 Gestalt Centre 62, Paul Street, London EC2A 4NA Tel: 020-7613-4480 Institute of Group Analysis 1, Daleham Gardens, London NW3 5BY Tel: 020-7431-2693 Metanoia Institute 13, North Common Road, London W5 2QB Tel: 020-8579-2505 Minster Centre 20, Lonsdale Road, Queens Park, London NW6 6RD Tel: 020-7644-6240 Nafsiyat 262, Holloway Road, London N7 6NE Tel: 020-7686-8666 Spectrum 7, Endymion Road, London N4 1EE Tel: 020-8341-2277 Tavistock Centre 120, Belsize Lane, London NW3 5BA Tel: 020-7435-7111 Westminster Pastoral Foundation (WPF) 23, Kensington Square, London W8 5HN Tel: 020-7361-4800 Women’s Therapy Centre 10, Manor Gardens, London N7 6JS Tel: 020-7263-6200 The Forward Project Unit 1 Bramber Court Bramber Road London W14 9PW 020 – 7381 8778 Free, one to one, couples and family counselling for Black adults in H&F. HELP Counselling Centre 57 Portobell Road London W11 3DB 020 – 7721 9974 Low cost (sliding scale) short and long term counselling -- LISTS / REGISTERS OF ACCREDITED COUNSELLORS/PSYCHOTHERAPISTS BACP Register (British Association of Counselling and Psychotherapy) Tel: 0870-443 5252 Website: www.bacp.co.uk UKCP Register (United Kingdom Council for Psychotherapy) Tel: 020-7436-3002 (ask for list of local psychotherapists) ———————————————————————————————————————————————————————————————————————————————————— Reduced Fee Psychotherapy British Psychoanalytic Association Website: http://www.psychoanalysis-bpa.org/low-fee-service.php Address: 37 Mapesbury Road, London NW2 4HJ Phone Number: 020 8452 9823 Fax Number: 020 8452 5182 Area: Mostly London Frequency: Four or five times weekly for a period of at least two years Fee Structure: £60 for initial consultation Minimum Fee: £2 to £25 depending on financial circumstances Apply to: Sally Rose – 07512 242 900 -- British Psychoanalytical Society and The Institute of Psychoanalysis Website: http://www.beyondthecouch.org.uk/clinic Address: Byron House, Maida Vale, London W9 2BT Phone Number: 020 7563 5002 Fax Number: 020 7563 5003 Email: clinic@iopa.org.uk -- The London Clinic of Psychoanalysis has a low-fee scheme whereby a limited number of low-fee places in psychoanalysis are available to those recommended following a Clinic consultation. Area: Most low-fee analyses are available in the London area, either at the Clinic or at the analyst’s private consulting room, but some places are also available in other parts of the UK. Frequency: five times weekly for 50 minute sessions for a period of at least two years. Fee Structure: Initial consultation fee: full fee £100, for those on low income £30. For analytic sessions, see above under minimum fees. Minimum Fee: The minimum fee is £5 per session but if this presents real difficulties, lower fees can be negotiated by agreement with the Clinical Director. Patients agree to pay what they can reasonably afford and this is reviewed annually. Apply to: The London Clinic of Psycho-Analysis by post to the above address or by telephone 020 7563 5002 or email clinic@iopa.org.uk Clinical Director: Ms Penelope Crick Clinic Administrator: Ms Trudy Turmer -- British Psychotherapy Foundation Website: http://www.britishpsychotherapyfoundation.org.uk/find-a-therapist Address: 37 Mapesbury Road, London NW2 4HJ Email Address: alicej@bpf-psychotherapy.org.uk Tel: 020 7482 2282 The British Psychotherapy Foundation offers a range of reduced fee schemes for those on low incomes prepared to attend intensive Psychotherapy, Psychoanalysis or Jungian Analysis for at least two years. There tend to be a limited number of places available and it is helpful for patients to have an initial assessment. Apply to: coordinators at http://www.britishpsychotherapyfoundation.org.uk/find-a-therapist -- Foundation for Psychotherapy and Counselling Address: 5 Maidstone Buildings Mews, London SE1 1GN Phone Number: 0207 795 0315 Email Address: grahamcallan@gmail.com The Referrals Service Manager has a database of qualified therapists able to offer low cost sessions. The Referrals Manager will provide a telephone consultation and then locate the most appropriate therapist for the patient’s needs as close as possible to their home, their place of work, or another suitable location. Area: The majority of therapists are located in London and surrounding areas, although we do have members nationwide. Frequency: 1-3 sessions offered by qualified therapists. Minimum Fee: According to income Apply to: The Referrals Manager on 0845 603 1960 or referrals@thefoundation-uk.org -- Society of Analytical Psychology Website: http://www.thesap.org.uk/consultation-services Address: 1 Daleham Gardens, London NW3 5BY Phone Number: 020 7435 7696 Fax Number: 020 7431 1495 Email: clinic@thesap.org.uk Applicants are asked to send a confidential letter describing themselves and their reasons for requesting analysis. A consultation is then offered with one of the Clinic Directors. Usually, but not always, analysis is with a trainee of the Society. Preference for clinic vacancies is given to those who have not had previous psychotherapy or psychiatric treatment. Area: Mostly London and Home Counties but occasional vacancies are available outside London. Frequency: 4-5 times weekly for a minimum of two years Fee Structure: £40 for initial consultation Minimum Fee: A minimum fee of £10 per session which may be reduced in special circumstances Apply to: The Director, C.G. Jung Clinic at the above address, by letter or telephone ———————————————————————————————————————————————————————————————————————————————————— Hi there My name is XXXXX, I suffer from depression. I’ve been attending the Lambeth South West Short Term Support Service over the last months. They’ve kindly pointed me in your direction. I believe I qualify for your Kyle Clinic services as my income is £XXK per year. Would it be possible to arrange a consultation? Feel free to call me on XXXXX XXXXXX if you’d like to discuss anything over the phone. Thanks XXXXX ———————————————————————————————————————————————————————————————————————————————————— Dear XXXXX, Many thanks for your email. In relation to the Kyle Clinic unfortunately we are not taking any referrals at the moment. If you are based in the Lambeth area, you could try Centre70 which is based in West Norwood, or The Awareness Centre which is based in Clapham as they offer low fee clinics. With best wishes Anne-Marie Scott Client Services Administrator ———————————————————————————————————————————————————————————————————————————————————— Hi My name is XXXXX, I suffer from depression. I’ve been attending the Lambeth South West Short Term Support Service over the last months. They pointed me in the direction of WPF.org.uk as I could qualify for their low-fees services being my income £XXK per year. Unfortunately they aren't taking any referrals at the moment but they very kindly forwarded me your details. Would it be possible to arrange a consultation? Feel free to call me on 07446 765266 if you’d like to discuss anything over the phone. Thanks Alfonso ———————————————————————————————————————————————————————————————————————————————————— Hi XXXXX Our centre is operating over 7 days per week, all low cost sessions will be face to face at either our Clapham or Tooting branch. Our fee is £20 per session, if you are receiving benefits, working tax credit, registered disabled, a pensioner or a student. Otherwise our fee is £35 per session. All these sessions are held with TRAINEE therapists. If you would like to see one of our counsellors within this service – we will send you an electronic triage form to fill out. Our private therapists are working face to face and some therapists can offer online sessions. Fees are on average £60-£75 per individual session or £80+ for a couples session. If you would like to see one of our therapists within this service, please let me know. We do not have any waiting lists, all our therapists are fully insured and you can also use your private health insurance to see some of our private therapists. Best wishes Elaine The Reception Team The Awareness Centre Limited 41 Abbeville Road, London SW4 9JX T: 020 8673 4545 www.theawarenesscentre.com IMPORTANT: This electronic message is for exclusive use by the person(s) to whom it is addressed, and may contain information that is confidential or privileged and exempt from disclosure under applicable law. If you are not an intended recipient, please be aware that any disclosure, dissemination, distribution or copying of this communication, or the use of its contents, is prohibited. If you have received this message in error, please immediately notify me of your inadvertent receipt and delete this message from all data storage systems. ————————————————————————————————————————————————————————————————————————————————————