Depression Key slides

1. Depression Key slides

2. Identification and assessment NICE CG 90, Oct 2009 • Be alert to possible depression (particularly in those with a past history of depression or a chronic physical health problem with associated functional impairment) and consider asking people who may have depression: • During the last month, have you often been bothered by feeling down, depressed or hopeless? • During the last month, have you often been bothered by little interest or pleasure in doing things? • If “yes” to either: follow-up(Whooley and Simon. New Engl J Med 2000;343:1942–50)

3. Identification and assessment NICE CG 90, Oct 2009 NICE Full Guideline 90, Oct 2009 • Confirmation requires more detailed clinical assessment; consider using a validated measure e.g. PHQ-9, HDRS, BDI • Comprehensive assessment should not rely solely on symptom count. Consider: • Degree of impairment and/or disability • Duration of episode • Always ask a person with depression directly about suicidal ideas and intent. PHQ = Patient Health Questionnaire HDRS = Hamilton Depression Rating Scale BDI = Beck Depression Inventory

4.  2 weeks At least 1 of X should be present Major depression (5 symptoms) Minor depression (2–4 symptoms) Diagnosis of major depression by DSM-IVWilliams, et al. JAMA 2002;287:1160–70; NICE CG 90, Oct 2009; Gruenberg AM, et al. 2005 http://media.wiley.com/product_data/excerpt/50/35273078/3527307850.pdf • Depressed mood • Loss of interest or pleasure (anhedonia) • Insomnia or hypoinsomnia • Appetite or weight change • Fatigue or loss of energy • Increased/decreased psychomotor activity • Guilt or feelings of worthlessness • Suicidal ideation X

5. Management of depressionThe stepped care modelNICE CG 90, Quick Reference Guide Oct 2009 Antidepressants for duration of illness + at least 6 months

6. NICE Step 2: persistent subthreshold depressive symptoms or mild to moderate depression (1)NICE CG 90, Oct 2009 • Consider offeringlow intensity psychosocial interventions: • Individual guided self-help based on cognitive behavioural therapy (CBT) principles • Computerised cognitive behavioural therapy (CCBT) • A structured physical activity programme • Choice of intervention should be guided by the patient’s preference • Group CBT may be offered for those who decline low-intensity treatments • Offer advice on sleep hygiene, if needed • Monitor • those judged to recover without a formal intervention • those with subthreshold depressive symptoms who request an intervention.

7. Using antidepressants for persistent subthreshold depressive symptoms or mild to moderate depressionNICE CG 90, Oct 2009 Antidepressants • Not recommended for the routine treatment of persistent subthreshold depressive symptoms or mild depression because the risk-benefit ratio is poor • Consider them for people with • Past history of moderate or severe depression • Initial presentation of subthreshold depression that has been present for a long period (typically >2 years) • Subthreshold depressive symptoms or mild depression that persists after other interventions.

8. NICE Step 3: persistent subthreshold depressive symptoms or mild to moderate depression with initial inadequate response; or moderate and severe depression NICE CG 90, Oct 2009 Options • Antidepressant (normally SSRI), or • High intensity psychological intervention • CBT (group or mindfulness-based) • Interpersonal Therapy (IPT) • Behavioural activation • Behavioural couples therapy, or • A combination of antidepressants and high-intensity psychological intervention (CBT or interpersonal therapy) if moderate or severe depression Choice depends on patient’s preference, duration of episode, trajectory of symptoms, previous illness course and treatment response, likelihood of adherence to treatment, likely side effects.

9. Which non-drug treatments are recommended?NICE CG 90, Oct 2009 • Low intensity psychosocial interventions: • Individual guided self-help based on cognitive behavioural therapy (CBT) principles • Computerised cognitive behavioural therapy (CCBT) • A structured physical activity programme • High intensity psychological interventions • CBT (group or mindfulness-based) • Interpersonal Therapy (IPT) • Behavioural activation • Behavioural couples therapy • Others • Counselling • Short-term psychodynamic psychotherapy • Group-based peer support programmes is a low-intensity option for those with chronic physical health problems.

10. Evidence on non-drug managementNICE Full Guideline 90, Oct 2009Mead GE, et al. The Cochrane Library 2009, Issue 4 Low-intensity psychosocial interventions • CCBT and guided self-help have some effect in reducing symptoms of depression vs. control (e.g. usual treatment, waitlist) • The effect of physical activity is unclear, but it has other health benefits • Recommended initial treatment for persistent subthreshold depressive symptoms or mild to moderate depression Higher-intensity psychological therapies (usually CBT or IPT) • Evidence suggesting CBT has some benefits over antidepressants (e.g. depression score at 12 months) and that adding CBT to antidepressants beneficial. Benefit of adding antidepressant to CBT less clear • Limited evidence hasn’t shown IPT, behavioural activation or couples therapy to be any better than CBT • May be used instead of an antidepressant for persistent subthreshold depressive symptoms, and for mild to moderate depression with an inadequate response initially • CBT or IPT should be used in combination with an antidepressant in moderate or severe depression.

11. Which antidepressants should be used?NICE CG 90, Oct 2009 • Should normally be a selective serotonin reuptake inhibitor (SSRI) in generic form because SSRIs are: • Equally effective as other antidepressants • Have a favourable risk-benefit ratio • Note that: • SSRIs are associated with an increased risk of bleeding (consider prescribing gastroprotective agent in older people who are taking NSAIDs) • Higher risk of drug interactions with fluoxetine, fluvoxamine and paroxetine (see BNF) • Higher incidence of discontinuation symptoms with paroxetine • Consider toxicity in overdose for those at significant risk of suicide. Be aware: • Venlafaxine associated with greater risk of death from overdose • Tricyclic antidepressants (except lofepramine) associated with greatest risk in overdose • Discuss drug choice with patient • Dosulepin should not be prescribed.

12. NICE on choice of antidepressantsNICE Full Guideline 90, Oct 2009 NICE CG 90, Oct 2009 • Antidepressants have largely equal efficacy and choice should be largely dependent on: • Side-effect profile • Patient preference • Previous experience of treatments • Propensity to cause discontinuation symptoms • Safety in overdose • Interaction potential • Normally choose SSRI in generic form – SSRIs have favourable risk-benefit ratio • Escitalopram wasn’t judged to have any clinically important advantages over other antidepressants • No advantage found for ‘dual action’ antidepressants (e.g. duloxetine▼and venlafaxine) over other drugs • Increased risk of suicidal ideation/behaviour in younger patients taking antidepressants.

13. Summary • Diagnosis of depression in adults should be based on DSM-IV and assessment should not rely solely on symptom count • In persistentsubthreshold depressive symptoms and mild to moderate depression, non-drug treatments e.g. CBT form the mainstay of treatment, and antidepressants are not usually recommended initially because the risk benefit ratio is poor • Antidepressants or psychological interventions or a combination should be considered in more severe or persistent disease. A combination is recommended for moderate or severe depression • Antidepressants have largely equal efficacy and choice should be largely dependent on several factors including side-effect profile, patient preference, previous experience of treatments and interaction potential (normally a generic SSRI).