DEPRESSION: management of depression in primary and secondary care

1. DEPRESSION: management of depression in primary and secondary care Dr. G. Garbutt GP ST2

2. DEPRESSION Depression is common, affecting 121 million people worldwide. Approximately 1% of people between in the UK between 16 – 65 have significant anxiety or depression Important cause of morbidity and mortality Produces the greatest decrement in health with other chronic diseases such as angina or arthritis. Commonly treated with lifestyle changes, antidepressants or psychological therapies or a combination of all three.

3. Diagnosis: • General Health Questionnaire • Geriatric Depression Scale • AMTS • Patient Health Questionnaire (PHQ – 2, PHQ – 9) • Hospital Anxiety and Depression Scale (HADS) • Beck Depression Inventory (BDI II)

4. Diagnosis: • Addition of a “help” question to two screening questions • “during the past month have you often been bothered by feeling down, depressed or hopeless?” • “during the past month have you often been bothered by little interest or pleasure in doing things?” • “is this something with which you would like help?” • Sensitivity 94% • Specificity 79% (increased from 57% with addition of help Q)

5. Diagnosis: DSM-IV • DSM-IV • 5 of the following over 2 week • At least one of • Depressed mood or irritability • Loss of interest or pleasure

6. Diagnosis: DSM-IV • Three or four of the following to make 5 • Appetite or weight loss • Sleep loss or change in pattern • Psychomotor agitation or retardation • Fatigue/energy loss • Worthlessness or guilt • Poor Concentration • Recurrent suicidal thoughts / thoughts of death

7. Entering the NICE guideline: • Low mood or loss of interest, usually accompanied by one or more of the following: • Low energy • Changes in appetite, weight or sleep pattern • Poor concentration • Feelings of guilt or worthlessness • Suicidal ideas

8. Step Care Model • Step 1: Recognition in primary care and general hospital settings • Step 2: Treatment of mild depression in primary care • Step 3: Treatment of moderate to severe depression in primary care • Step 4: Treatment of depression by mental health specialists • Step 5: Inpatient treatment for depression

9. Key priorities for implementation • Screening in primary care and general hospital settings • Watchful waiting • Exercise and lifestyle changes • Antidepressants in mild depression • Guided self-help • Short-term psychological treatment

10. Key priorities for implementation • Prescription of an SSRI • Tolerance and craving, and discontinuation /withdrawal symptoms • Initial presentation of severe depression • Maintenance treatment with antidepressants • Combined treatment for treatment-resistant depression • CBT for recurrent depression

11. Monitoring risk • See patients who are: • At increased risk of suicide • Younger than 30 years old • 1 week after starting treatment • Monitor frequently until the risk is no longer significant. • High risk of suicide • limit quantity of antidepressants. • consider additional support • more frequent contacts with primary care staff • telephone contacts.

12. Monitoring risk • Monitor for: • Akathisia • Suicidal ideas • Increased anxiety and agitation • In early stages of treatment with SSRI. • Advise patients of the risk of these symptoms • seek help promptly • Marked and/or prolonged akathisia or agitation • review antidepressant

13. Stopping or reducing antidepressants: • Inform about possibility of discontinuation /withdrawal symptoms. • Usually mild and self-limiting • Occasionally severe, if stopped abruptly. • Advise to take their drugs as prescribed • particularly drugs with a short half-life • paroxetine and venlafaxine

14. Stopping or reducing antidepressants: • Reduce over a 4-week period • mild discontinuation/withdrawal symptoms, reassure and monitor. • Severe symptoms • consider reintroducing original antidepressant at effective dose • or another antidepressant with a longer half-life from same class • and reduce gradually while monitoring.

15. Limited response to initial treatment in moderate and severe depression • Choices for a second antidepressant: • different SSRI or mirtazapine; • Alternatives: moclobemide, reboxetine and lofepramine. • Consider other TCA (except dosulepin) and venlafaxine, for severe depression. • Switching • Gradual, modest, incremental increases of dose • risk of interaction • risk of serotonin syndrome • Features: confusion, delirium, shivering, sweating, changes in blood pressure, and myoclonus.

16. Special considerations when switching to venlafaxine • Take into account: • likelihood of patients stopping because of side effects • higher cost • Control pre-existing hypertension. • Do not prescribe for patients with uncontrolled HTN • Only prescribe at 300 mg per day • more under supervision of a specialist mental health doctor • Monitor: • BP at initiation • Regularly during treatment (particularly during titration) • Reduce dose or consider discontinuation if sustained increase BP. • Check for signs and symptoms of cardiac dysfunction.

19. References • NICE Quick reference guide (amended April 2007): Depression: management of depression in primary and secondary care (Issue date: December 2004) • Assessing relative efficacy of antidepressants: http://www.medicine.ox.ac.uk/bandolier/booth/mental/cipriani.html • Cipriani et al., Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis. Lancet 2009 373: 748-758. • Weel-Baumgarten et al., The validity of the diagnosis of depression in general practice: is using criteria for diagnosis as a routine the answer? Br J Gen Pract. 2000 April; 50(453): 284–287. • Middleton et al., (Editorial) NICE guidelines for the management of depression. BMJ, Feb 2005; 330: 267 – 268. • Kessler et al., Screening for depression in primary care (Editorial). British Journal of General Practice, September 2005 659. • Arroll et al., Effect of the addition of a "help" question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ Oct 2005; 331: 884. • Paton et al., EDITORIALS: SSRIs and gastrointestinal bleedingBMJ Sep 2005; 331: 529 – 530 • Szegedi et al., Acute treatment of moderate to severe depression with hypericum extract WS 5570 (St John's wort): randomised controlled double blind non-inferiority trial versus paroxetine BMJ Mar 2005; 330: 503