Bay Navigator

Mental Health
Depression

Red Flags

If there is any immediate and imminent danger to either the patient or the safety of others then it may be necessary to call the police for assistance on 111.
If you require immediate assessment due to concerns around risk and safety as below:
  • Serious suicidal intent – is actively suicidal, has a current suicide plan or is at risk of self–harm.
  • Psychotic symptoms.
  • Severe self-neglect.
  • Is a risk to others.
CONTACT:
  • EBOP: 0800 7774545 or during business hours on 07 306 0154
  • WBOP: 0800 800508 or during business hours 07 579 8329
  • For West BOP over 65s: MHSOP – 07 579 8335 (8-5pm). Ask to speak to Intake After Hours (as above).
If the patient requires compulsory assessment then they will need the Mental Health Act 1992. If this is needed then contact the Duty Authorised Officer using the 0800 numbers above and they will provide the necessary forms.
Referral to mental health services for assessment/admission may also be indicated for severely ill patients who:
  • lack adequate support outside of a hospital setting.
  • have complicated psychiatric or general medical conditions.
  • carry significant risk to themselves or others and cannot be managed safely outside a hospital setting.

Background

1. Early Detection/Clinical Presentation

High Risk Groups

Previous history of:

  • Depression.
  • Mania or bipolar disorder.
  • Suicide attempt.

Co-existing physical illness:

  • Endocrinological.
  • Neurological.
  • Life-threatening.
  • Disabling.
  • Stigmatising.
  • Painful.
  • Deforming.

Other mental health problems.

Family history of mental health problems.

Ethnicity – Maori have a higher rate of suicide compared with
non-Maori population and higher rates of depressive disorder.

Social deprivation.

 

Clinical Presentation

Presenting symptoms/signs:

  • Persistent sense of sadness, anxiety or emptiness.
  • Lack of motivation and interest.
  • Feelings of hopelessness.
  • Feelings of worthlessness and/or guilt.
  • Marked physical slowness or agitation.
  • Anhedonia.
  • Range of somatic symptoms i.e., appetite and weight loss, reduced sleep, loss of energy or fatigue.

Age

  • Younger patients show more behavioural symptoms
    and irritability.
  • Older adults have more somatic symptoms, fewer complaints of low mood and more memory problems.

Presenting symptoms – Atypical:

  • Weight gain.
  • Reactive mood.
  • Increased appetite.
  • Excessive sleepiness.

Physical symptoms:

  • Pain.
  • Constant tiredness.
  1. The following can accompany or conceal depression:
    • Anxiety:
      • When depression is accompanied by anxiety, the first priority should be to treat the depression.
      • When the person has an anxiety disorder and co-morbid depression or depressive symptoms consider treating the anxiety disorder first (if depression is relatively mild compared to anxiety) – effective treatment of the anxiety disorder will often improve the depression or depressive symptoms.
    • Insomnia.
    • Worries about social problems, e.g. financial difficulties.
    • Increased irritability and hostility.
    • Increased drug and alcohol use.

Assessment

  1. Initial Assessment
    • Consider asking the following simple screening questions:
      1. During the last month, have you often been bothered by feeling down, depressed, or hopeless?
      2. During the last month, have you often been bothered by having little interest or pleasure in doing things?
    • If 'Yes' then ask - Is this something with which you would like help? – No/ Yes/Yes but not now
    • History – key points to ask Past history Medications – the following may be associated with major depression
      • Current symptoms.
      • Duration of symptoms.
      • Severity of symptoms.
      • Functional impairment.
      • Response to previous treatment.
      • Quality of interpersonal relationships.
      • Living conditions and social isolation.
      • Alcohol, illicit substance, or prescribed medication use.
      • Recent losses, including bereavement.
      • Psychosocial stressors, e.g. loss, financial difficulties.
      • History of self-harm.
      • History of suicide attempts.
      • Past history of mania or hypomania
        or mixed episodes.
      • Past history of depression.
      • Response to any treatment for depression
        in the past.

       

      • Corticosteroids.
      • Interferon.
      • Methyldopa.
      • Isotretinoin.
      • Varenicline.
      • Hormonal Therapy.

      Investigations - Biochemistry

      Investigations - Haematology

      Investigations - Radiology

      • HBA1c.
      • Urea, Electrolytes, Creatinine.
      • LFTs.
      • TFTs.
      • Calcium Levels.
      • FBC.
      • CRP.
      • Urinary or blood drug screen if
        appropriate.
      • Consider specialist advice on brain imaging if unexplained headaches, personality changes, signs of space occupying lesion, convulsions, altered state of alertness.
    • Using Te Whare Tapa Wha as a model to help understand the totality of a patient’s health may be useful, particularly with Maori patients but equally with all patients who present with depression.
  2. Scoring Tools
  3. Diagnosis
    • DSM – IV criteria:

      Requires a minimum of 5 out of 9 symptoms, including depressed mood and/or anhedonia. Symptoms:

      • Depressed mood by self-report or observations by others.
      • Loss of interest or pleasure.
      • Feelings of worthlessness/guilt.
      • Recurrent thoughts of death, suicidal thoughts or actual suicide attempts.
      • Diminished ability to think, concentrate or indecisiveness.
      • Psychomotor agitation or retardation.
      • Insomnia or hypersomnia.
      • Significant appetite and/or weight loss.
      • Loss of energy or fatigue.

      ICD-10 criteria

      Requires 4 out of 10 symptoms, including at least two of depressive mood, anhedonia, and energy loss.

      Duration of symptoms: 

      In order to make a diagnosis of depression, symptoms should have been present for at least 2 weeks.

      If depression has persisted for more than 2 years, the patient is said to have chronic depression.

  4. Bipolar Disorder Other Psychiatric conditions Non-Psychiatric

    Episodes of mania, hypomania – overactive disinhibited behaviour, previous psychotic symptoms, history of previous episodes of possible mania or hypomania, mixture of both manic and depressive symptoms.

    http://www.bpac.org.nz/BPJ/2014/July/bipolar.aspx

    • Generalised anxiety disorder.
    • Post-traumatic stress disorder.
    • Social phobia.
    • Panic disorder.
    • Obsessive compulsive disorder.
    • Personality disorder.
    • Psychotic disorder.
    • Adjustment disorder.
    • Bereavement.
    • Dementia.
    • Alcohol abuse or dependence.
    • Illicit substance misuse.
    • Anabolic steroids.
    • Cannabis.
    • Cocaine.
    • Narcotics.
    Adverse Drug Effects Medical Conditions

     

     

    • Centrally acting anti-hypertensives.
    • Lipid-soluble beta blockers.
    • Central nervous system depressants.
    • Opioid analgesics.
    • Isotretinoin.
    • Benzodiazepines.
    • Corticosteroids.
    • H2-receptor antagonists.
    • Chemotherapy agents.
    • Levo-dopa.
    • NSAIDS.
    • Oral Contraceptives.

     

    • Endocrine disorders – hypothyroidism, Cushing’s disease, adrenal insufficiency, hyperparathyroidism.
    • Cancer, e.g. brain tumor.
    • Diabetes.
    • Cardiac disease.
    • Parkinson’s disease.
    • Cerebrovascular disease, e.g. stroke, subarachnoid haemorrhage.
    • Autoimmune diseases.
    • Post-polio syndrome.
    • HIV.
    • Chronic pain.
    • Fibromyalgia/chronic fatigue.

     

  5. Risk Assessment/Severity
    • Assessment of Suicide Risk (BPAC - Assessment of adults with depression in primary care) can be challenging as there is no evidence for absolute markers that indicate presence or intensity of suicide risk. Assessment also only provides a snapshot of risk at a given time. Therefore, assessment of suicide risk should be ongoing during treatment as new triggers can emerge even if a person’s mental state is improving or staying the same.
    • The most immediately important factors to consider are contextual triggering factors and current mental state:
      • Intent/definite plan.
      • Lethality of likely means.
      • Access to means.
      • Presence of risk factors (e.g. mental or physical illness, chronic pain, alcohol use).
      • Psychosocial triggers.
      • Lack or presence of protective factors.
    • It is important to realise that any individual’s suicide risk may increase as a consequence of an acute stressor or situation. For example, chronic risk factors such as male gender, childhood adversity or chronic pain remain static but an acute stressor such as a relationship breakdown, or drinking binges, may rapidly elevate the person’s risk of suicide. Therefore recognition of potential dynamic factors is important in any management plan.
    • Deliberate self-harm, such as cutting, is a non-suicidal behaviour which is used as an attempt to cope and manage. It must be recognised that the emotional distress that leads to self-harm can also lead to suicidal thoughts and actions.
    • This assessment tool is available for professionals to help guide suicide risk (page 162 – 2 pages Appendix C).
      • Ask about self–neglect or risk of harm to dependants.
      • Assess risk of violence.
      • Look for signs of psychosis.
    • Mild depression Moderate depression Severe depression

      Few symptoms in excess of the 5 required to make a diagnosis and only mild functional impairment.

      More than the minimum of symptoms are present and there is moderate functional impairment.

      Symptoms that cause a marked interference with functioning.

      May be with or without psychotic symptoms.

    • The Adult Community Mental Health Service has a triage intake process that can be found here and which uses a triage scale that takes into account risk assessments. This may be of value to reference when considering a referral into their service.

Management

  1. Initial Treatment for Mild Depression
  2. Initial Treatment for Moderate Depression
    • Non-pharmacological treatment
    • Depression Pathway - Moderate Depression
      Pharmacological treatment

      There is a range of antidepressant drug classes which can be used and they are equal in effectiveness in clinical studies although individual patients may vary. The following tables may help guide the choice of which drug to initiate with a particular patient:

      Drug class Tolerability

      SSRI’s – fluoxetine, citalopram, escitalopram, paroxetine, sertraline

      • Usually best to give as single daily dose each morning but if sedation occurs can be taken at night.
      • Start with lower doses to avoid discontinuation due to side effects.
      • Half tablets for a few days and then increase.

       

       

      • Usually activating- except paroxetine.
      • Nausea very common initially.
      • Sexual dysfunction.
      • Hyponatraemia.
      • QT prolongation – particularly in those with other risk factors, i.e. congenital long QT syndrome, recent MI, hypokalaemia, hypomagnesemia.
      • Increased risk of upper GI bleeding - particularly in those concurrently using anti platelets and antithrombotic medications, NSAIDs.
      • Fluoxetine – long half-life so lowest risk of discontinuation effects, less likely to cause weight gain, risk of drug interactions.
      • Citalopram – well–tolerated, low risk of drug interactions.
      • Escitalopram – slightly lower risk of QT prolongation.
      • Paroxetine – high risk of discontinuation effects, weight gain, sedation, risk of drug interactions.
      • Sertraline – slightly higher incidence of diarrhoea.

      SNRI’s – venlafaxine

      • Start low dose to reduce impact of side effects.
      • Higher dose more effective against anxiety symptoms (need >150mg/day for noradrenaline re-uptake effect).
      • Can cause increased blood pressure.
      • Short half-life so can have high risk of discontinuation effects.

      MAOIs - moclobemide

      • Reversible selective MAOI.
      • Also used in social anxiety disorders.

      Tricyclic antidepressants

      Tend to be sedating so usually given at night.

      Start with very low doses to avoid discontinuation due to adverse effects, i.e. nortriptyline start at 5-10mg and then slowly increase.

      • Anti-cholinergic side effects – dry mouth, blurred vision, constipation, urinary retention.
      • Very toxic in overdose.

      Mirtazapine

      • Can be sedating due to its histamine H1-antagonistic activity.
      • Low liability for sexual side effects.
      • Possible weight gain.

      Bupropion – dopamine and noradrenaline re-uptake inhibitor.

      • Not licensed for depression in NZ.
      • Less sedating, more activating and can cause insomnia.
      • Low liability for sexual side effects.
      • Can cause weight loss.

       

      For more detailed information there is a comprehensive resource regarding pharmacological management of depression. Please note this was published in 2009 (so some of the information is out of date).

      There are also considerations with patients who have other co-morbidities:

      Cardiovascular disease

      • Caution with increased risk of upper GI bleeding with combination of SSRI and SNRIs and antiplatelets and anti-thrombotics, NSAIDs.
      • Caution with venlafaxine and side effect of hypertension.
      • Recent ACS – avoid TCAs and choose SSRIs if possible.

      Epilepsy

      • Avoid bupropion.
      • TCAs lower seizure threshold.

       

      Fibromyalgia / Centralised Pain Syndromes

      • Consider TCA, venlafaxine as these medications have been shown to have analgesic efficacy in some pain conditions

      Insomnia

      • TCAs and mirtazapine are sedating
      • Avoid bupropion

      Weight Gain

      •          Avoid TCAs, mirtazapine and paroxetine.
      •          Fluoxetine may be less likely to cause weight gain than other SSRIs.
      •          Bupropion can cause weight loss.

      Osteoporosis

      • High dose of SSRIs can increase fracture risk.

       

      The following table details some of the more clinically relevant drug interactions:

      PHARMACOKINETIC (altered metabolism) PHARMACODYNAMIC (additive effects)
      • Fluoxetine, paroxetine, bupropion
        • Moderate to strong inhibitors of CYP 2D6 so can INCREASE exposure to the following medications: 
          • aripiprazole, atomoxetine, carvedilol, clozapine, donepezil, galantamine, metoprolol, risperidone, tricyclic antidepressants.
      • St Johns Wort:
        • Potent inducer of CYP3A4, 2C9 and P-glycoprotein so can DECREASE concentrations of other medications, reports of clinical significance include: 
          • cyclosporin, tacrolimus and oral contraceptives.

      SSRIs – citalopram, escitalopram, fluoxetine, paroxetine, sertraline, venlafaxine, mirtazapine.

      • Serotonin syndrome  additive risk with other serotonergic medication, e.g. tramadol, fentanyl, St Johns Wort, linezolid, buspirone, ondansetron, MAOIS (contraindicated).
      • Increased bleeding risk with antiplatelet, anticoagulants, NSAIDS.
      • Hyponatraemia with thiazides, loop diuretics, carbamazepine.
      • QT prolongation with antipsychotics, TCAs, metoclopramide, Domperidone, ondansetron, methadone, antiarrhythmics, erythromycin, moxifloxacin.
  3. Initial Treatment for Severe Depression/Complex Presentation
    • Refer to Community Mental Health (via usual referral process, i.e. eReferral)
    • Severe depression:
      • Consists of symptoms that cause a marked interference with functioning.
      • May be with or without psychotic symptoms.
    • It is not within the scope of this pathway to give management guidelines for severe depression – referral to secondary care is appropriate.
    • Refer to Map of Medicine pathway on Depression- severe and complex (now accessible via Midland Health Pathways).
    • Assess risk – refer to risk assessment and refer urgently those who have acute suicidal risk.
    • Referral to Community Mental Health may also be appropriate if:
      • the patient has suspected bipolar disorder
      • there has been treatment resistance. This is defined as a lack of satisfactory response after a trial of two anti-depressants given sequentially at an adequate dose for an adequate time, with or without psychological therapy.
    • Referral to Mental Health Services may be indicated for severely ill patients who:
      • lack adequate support outside of a hospital setting
      • have complicated psychiatric or general medical conditions
      • carry significant risk to themselves or others but cannot be managed safely outside a hospital setting
    • The Adult Community Mental Health Service has a triage intake process that can be found here and which uses a triage scale that takes into account risk assessments. This may be of value to reference when considering a referral into their service.
  4. Review for improvement
    • Review regularly once diagnosis has been made and treatment initiated.
    • Initially within 1-2 weeks. Consider phone review after a week if needed. This can be made by any member of a primary health team, i.e. practice nurse.
    • Continue to monitor risk and ask about suicide. In the first few days of treatment with an SSRI an increase in anxiety, restlessness or agitation may occur. This can be distressing and may be associated with increased suicidality.
    • Review again after 4 weeks and then ideally every 3 months until decision made to cease treatment.
    • Consider using Kessler Score or PhQ-9 to monitor progress see 

      These scoring tools can be used as guides to detect and assess the severity of depression but must be used alongside a fuller clinical assessment and should not be used to determine the need for treatment.

      Best Practice also has links to PHQ-9 and Kessler 10 listed in the forms menu.

    • If antidepressants have been prescribed then ask about side effects particularly:
      • symptoms of hyponatraemia – dizziness, lethargy, nausea, confusion, cramps, seizures
      • hypertension/ hypotension – if taking venlafaxine
      • mania
      • anti-cholinergic symptoms
      • sedation, insomnia, activation, changes in weight, sexual dysfunction.
    • Some side effects can be managed and will decrease with time, i.e. mild nausea and headaches. This information can be given to a patient to help manage their expectations.
    • Sexual dysfunction is a common problem with many medications particularly SSRIs.
    • The following guide provides a framework for managing antidepressant-induced sexual dysfunction:
      • rule out other causes
      • wait: some patients will improve within six months
      • reduce dose: risk of relapse
      • switch to antidepressant with lower risk of sexual dysfunction (e.g. mirtazapine, moclobemide, bupropion) -NZF switch table
      • add low dose of bupropion or mirtazapine (more evidence for bupropion than mirtazapine). Women are more likely to respond to bupropion than sildenafil or tadalafil.
      • add sildenafil or tadalafil (more effective for men than women)
      • exercise: high drop-out rate.
    • Medicine Anticholinergic Agitation/
      insomnia
      GI* Sedation Weight gain Sexual dysfunction QT prolongation

      SSRIs

       

       

       

       

       

       

       

      Citalopram

      0

      +

      +

      0

      +

      +++

      +

      Escitalopram

      0

      +

      +

      0

      +

      +++

      +

      Fluoxetine

      0

      ++

      +

      0

      +

      +++

      +

      Paroxetine

      +

      +

      +

      +

      ++

      ++++

      0/+

      Sertraline

      0

      ++

      ++

      0

      +

      +++

      0/+

       

       

       

       

       

       

       

       

      SNRI/NaSSA

       

       

       

       

       

       

       

      Venlafaxine

      0

      +

      ++

      0/+

      +

      +++

      +

      Mirtazapine

      +

      0

      0

      ++++

      ++++

      +

      +

       

       

       

       

       

       

       

       

      TCAs

       

       

       

       

       

       

       

      Amitriptyline

      ++++

      0

      +

      ++++

      ++++

      ++

      +++

      Clomipramine

      ++++

      +

      +

      ++++

      ++++

      ++

      ++

      Dosulepin (dothiepin)

      +++

      0

      +

      ++++

      ++++

      ++

      +++

      Doxepin

      +++

      0

      0

      +++

      ++++

      ++

      +++

      Imipramine

      +++

      +

      +

      +++

      ++++

      ++

      +++

      Nortriptyline

      ++

      0

      0

      ++

      +

      ++

      +++

       

       

       

       

       

       

       

       

      MAOIs

       

       

       

       

       

       

       

      Moclobemide (RIMA)

      +

      0

      +

      0/+

      0/+

      0/+

      0/+

      Phenelzine

      +

      +

      +

      ++

      ++

      +++

      0

       

       

       

       

       

       

       

       

      Atypical

       

       

       

       

       

       

       

      Bupropion

      0

      +

      +

      0

      0

      0

      +

    • It is also important to identify any possibility of serotonin syndrome which is a severe form of serotonin toxicity. It can be mild with tremor and low-grade restlessness or present with more severe symptoms as below. This may require supportive management and cessation of the causative agents. If severe the patient may require referral to an emergency department as it can be fatal.
    • Clinical Features Contributing factors

      Abdominal cramps, agitation, diarrhoea, myoclonus, tremulousness, coma, tachycardia, hypotension, disorientation, profuse sweating, hyperpyrexia.

      • Overdosage
      • Drug interaction, especially SSRI + MAOI or SSRI + serotonergic TCA (e.g. clomipramine, amitriptyline, imipramine)
      • Inadequate drug-free interval in changing medications
      • Idiosyncratic reaction
    • There are several drugs and herbal products that have serotonergic activity and therefore can cause serotonin syndrome when combined or given alone at high doses.
    • Class Drugs

      antidepressants

      TCAs (especially clomipramine), MAOIs (including moclobemide), SSRIs, mirtazapine, venlafaxine, St John’s Wort

      opioids

      Tramadol, pethidine, dextromethorphan

      stimulants

      Amphetamines, sibutramine

      5HT1 agonists

      Sumatriptan, naratriptan, zolmitriptan

      others

      Ecstasy, LSD, cocaine. Selegiline, tryptophan, buspirone, lithium, linezolid

    • For more information on Serotonin syndrome/toxicity – Medsafe Prescriber Update
    • Inadequate response to treatment
    • Although it can take 8-12 weeks to achieve full antidepressant response, there is some evidence that response at 4 weeks correlates reasonably well with later outcomes.
    • If there is no improvement after 4 weeks:
      • check medication is being taken as prescribed
      • re-evaluate diagnosis
      • ask about alcohol +/- substance abuse
      • adding in psychological therapy if not originally offered
      • medication options are:
        • increase dose
        • switch to a different anti-depressant. There is little difference in outcomes between switching within the same class or to a different class.
    • NZ Formulary has a very useful table for switching anti-depressants.
    • If there has been some improvement after 4 weeks, consider increased dose of antidepressant if possible and tolerated and reassess after 4 weeks.
    • There are evidence-based options for augmenting antidepressant treatments which can include the following:
    • Augmentation: antidepressant plus non-antidepressant
      • Antipsychotics:
        • Aripiprazole
        • Olanzapine
        • Quetiapine
        • Risperidone
      • Lithium
      • Levothyroxine
    • Discussion with a psychiatrist would be advised if considering these.
    • Consider referral to Community Mental Health Services if patient is treatment resistant, this is defined as a lack of satisfactory response after a trial of two anti-depressants given sequentially at an adequate dose for an adequate time, with or without psychological therapy.
  5. Refer to Community Mental Health
    • Consider referral to Community Mental Health Services if patient is treatment resistant. This is defined as a lack of satisfactory response after a trial of two antidepressants, given sequentially at an adequate dose for an adequate time, with or without psychological therapy. 
    • Refer to Community Mental Health (via usual referral process, i.e. eReferral)
    • Or contact:
      • EBOP: 0800 7774545 or during business hours on 07 306 0154
      • WBOP: 0800 800508 or during business hours 07 579 8329
      • For West BOP over 65s: MHSOP – 07 579 8335 (8-5pm). Ask to speak to Intake After Hours (as above).
    • The Adult Community Mental Health Service has a triage intake process that can be found here and which uses a Triage Scale that takes into account risk assessments. This may be of value to reference when considering a referral into their service.
  6. If yes, improvement
    • Remission
      • In DSM-IV remission is where a person has no depressive symptoms for at least 2 months, they have minimal signs of the illness, and have a PHQ-9 score of under 4.
      • Following 9 months of remission there should be a review for the need to stop any anti-depressants.
      • Reviewing the ongoing need for antidepressants should take into account the previous history of depressive episodes, any residual symptoms, and concurrent health or psychosocial problems.
    • Relapse prevention
      • There is a high risk of relapse after a depressive episode within the first 6 months.
        • It is therefore important to continue treatment following an acute response in depressive disorders.
        • The risk of relapse declines with time in remission.
        • There is a high risk of relapse in the elderly with co-morbid illness.
    • Stopping or reducing medication
      • Consider stopping medication 9-12 months after remission is reached if the patient has minimal symptoms and has good daily functioning. Take into account the patient's previous history of depressive episodes.
      • If this is the patient's second or subsequent episode, and they have responded well, consider continuing on medication indefinitely. 
      • Educate and monitor for discontinuation symptoms. Usually need to gradually discontinue medication over a period of 4 weeks.
      • Onset of discontinuation symptoms is usually within 5 days and rarely lasts more than 1-2 weeks but can be very troublesome.
      • Discontinuation Symptoms
        • Dizziness
        • Tingling
        • Fatigue
        • Anxiety
        • Diarrhoea
        • Flu-like symptoms  
        • Tearfulness
        • Irritability
        • Nausea
        • Paresthesia
        • Headache
        • Shock-like symptoms
        • Excessive dreaming
        • Insomnia
    • Maintenance
      • Consider maintenance for those who have had:
        • 3 or more prior major depressive episodes
        • presence of residual symptoms
        • early age of onset
        • family history.
    • Other factors that may inform the decision for maintenance therapy include:
      • patient preference
      • probability of recurrence
      • the frequency and severity of prior depressive episodes (including psychosis and suicide risk)
      • the persistence of depressive symptoms after recovery
      • the presence of co-occurring disorders.

Additional Information

Disclaimer: These pathways, for the care and management of patients within Bay of Plenty, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.