Depression & Antidepressants

1. Depression&Antidepressants Fareed Bhatti Pennine VTS - November 2009

2. Format of Presentation • Split into subgroups …..( if possible) • 3 presenters • About 15-20 minutes • Covered Topics - New NICE guidelines for Depression(Oct 2009) - How to start, switching between antidepressants & stopping them. - Individual characteristics of Antidepressants - Antidepressants in Pregnancy Some AKT style questions (MCQs) thrown in somewhere….. Chocolates for right answers!

3. Why is it important? Worldwide lifetime incidence ~4-10% for major depression 2.5% and 5% for dysthymia ( chronic low grade symptoms) Numbers for UK ( King’s Fund report 2006): In 2006 1.24 million people with depression in England, By 2026 projected to rise by 17 % to 1.45 million. Costs: . In 2007 the total cost of services for depression in England ~ £1.7 billion with lost employment £7.5 billion. By 2026 cost ~ £3 billion & with lost employment £12.2 billion. QOF points (2009-2010) = 53 for depression • DM/CVD pts screened for depression in past 15 months - 8 points • New diagnosis in past year- formal assessment(e.g.PHQ9) - 25 points • Re-evaluate using the same tool in 5-12 weeks - 20 points

4. Question 1 • What are the two screening questions for depression in primary care? (Chocolates only for telling both!)

5. Answer • 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?

6. Question 2 • Name any 7 symptoms that you would use to assess for depression?

7. Answer • The somatic features of depression include: • loss of appetite • weight loss • constipation • insomnia or hypersomnia • amenorrhoea • low libido • psychomotor retardation or agitation Symptoms of general low mood include: • sadness and tearfullness • low self-esteem • guilt • pessimism • helplessness • hopelessness • apathy • loss of interests • anhedonia • loss of concentration • depersonalisation • Paranoia Anxiety symptoms of depression include: • tension • apprehension • phobic disorders • Psychotic symptoms (severe depression): • hallucinations typically derogatory auditory hallucinations • delusions e.g. delusions of worthlessness

8. Severities of Depression • Subthreshold: < 5 symptoms. • Mild Depression : Just above 5 with minor functional impairment. • Moderate: Symptoms or functional impairment between mild and severe. • Severe: Most symptoms, marked functional impairment.

9. New NICE Guidelines for Depression-Salient points • Assessment Principles-duration and severity with degree of impairment should also be considered. • Encompasses adults with chronic illnesses as well. • Sub threshold depression recognised and guidelines given. • Diagnostic criteria has been changed from ICD-10 to DSM-IV so psychosocial therapies can be matched to the illness more appropriately. • Clearer role of psychosocial interventions defined but implications for existing overstretched services. • More accountability for the psychosocial interventions. • Guidance for relapse prevention-talking therapies+ meds.

10. Treatment of Depression with Chronic Illness Collaborative care between primary and secondary care for long term Rx and follow up - High Intensity psychosocial intervention - SSRI - Combination of both Low Intensity psychosocial intervention Treatment of Persistent sub-threshold(PST) Depressive symptoms

11. Important difference from previous guidance: . Not routinely but can consider antidepressant for • Subthreshold depressive symptoms with past history of moderate or severe depression. • Mild depression that complicates care of physical health problem • Initial presentation of PST > 2 years • PST or mild depression persisting after other interventions

12. Stepped Care Model

13. Psychosocial interventions Low-intensity psychosocial interventions Indications: • For PST depressive symptoms or mild to moderate depression +/- chronic physical health problem, • PST symptoms that complicate care of the chronic physical health problem • Preventing relapse Types (guided by the patient’s preference) – Structured group physical activity programme – Group-based peer support (self-help) programme – Individual guided self-help based on the principles of CBT – Computerised CBT -- Group based mindfulness –based CBT High-intensity psychological interventions Indications • Treatment for moderate depression • For patients with initial presentation of moderate depression and a chronic physical health • Preventing relapse of depression –some cases Types -- Group-based CBT / Interpersonal therapy/ behavioural activation – Individual CBT or -- Behavioural couples therapy for selected patients

14. Starting antidepressants The consultation: - Give choice - Explore I,C &Es - Discuss no addiction potential - Shouldn't discontinue suddenly - Need to continue beyond remission - Safety netting and follow up. Follow up - <30yrs or high risk of suicide- see after 1 week and then frequently. - Less risk of suicide- see after 2 weeks then 2-4 weeks uptil 3 months then longer intervals. Should the antidepressants ever be put on patient’s repeat medication?

15. Drug titration • If SEs early on monitor& reassure OR stop and change OR upto 2 weeks addition of benzodiazepine (according to symptoms and not for chronic anxiety). - 2-4 weeks Minimal response check compliance & increase support OR increase dose OR switch antidepressant Some improvement Continue for another 2-4 weeks & change antidepressant if inadequate response, SEs or patient choice.

16. Choosing and changing antidepressants Choosing: - Patient choice • SSRIs - Generic SSRI 1st line- consider PPI in elderly or if on aspirin/ NSAIDs etc. - Sertraline /Citalopram for people with chronic illnesses as lower interactions. - Higher interactions with Fluoxetine, Fluvoxamine and Paroxetine. - Paroxetine – higher discontinuation symptoms. • TCAs - Higher toxicity risk in overdose except Lofepramine, so increase dose slowly. - Dosulepin(TCA) –not recommended because of high risk of toxicity with OD. • MAO Inhibitors/ Lithium or lithium augmentation-Psychiatrists Changing: Venlafaxine Different SSRI or better tolerated newer generation drug SSRI Another class TCAs

18. Question 3 A 64 years old lady comes to see you 3 weeks after her husband’s death. You notice she looks depressed. She reports poor sleep , appetite, loss of pleasure in activities and feelings of depersonalisation. What would you suggest • Sertraline. • St John’s wort with light therapy. • Bereavement counselling. • Any combination of above.

19. Answer 3 Careful monitoring and Bereavement counselling. Although has a lot of features of depression and might very well develop into that, at present secondary to bereavement and therefore doesn’t qualify as true endogenous depression.

20. Augment meds if needed Stopping antidepressants & preventing relapse • Started antidepressants • Thinking about stopping? • Is it recurrent illness • Any residual symptoms or • - Continuing psychosocial /physical health problems Remission achieved Psychological interventions- CBT or mindfulness based CBT • Gradually reduce the dose over a 4 weeks, can be slower. Fluoxetine can usually be stopped over a shorter period(longer half life). • Some drugs like paroxetine and venlafaxine have a shorter half-life and more chances of discontinuation syndromes. (See GP notebook for table for reducing doses) • Discontinuation symptoms Management : - Mild = reassure and monitor. - Severe = reintroduction of original antidepressant at effective dose(or another antidepressant with a longer halflife) Continue Meds for 6 more months same dose • Significant risk of relapse • OR • Hx of Recurrent depression Continue meds for 2 years and then review

21. The End