Does Depression get you down?

1. Nick Venters Consultant Psychiatrist. Does Depression get you down?

2. It’s very common, but perhaps not one in four of the population. • 1 in 15 W0men. 1 in 30 men. (Metzer 1994) • You will each see 60 to 100 new cases a year in primary care • 30000 workers in Britain believe they suffer from work-related stress, anxiety or depression(HSE 1995) • Costs the UK economy £3.4 Billion

3. One month prevalence rates worldwide show similar rates. Edinburgh 5.9% London 7% USA 5.2% Athens7.4% Canberra 4.8% Uslun and Sartorius 1993 WPA/PTD Educational Programme on Depressive Disorders

4. It’s been around a while. • 400BC Hippocrates “The Nature of Man” Mania=Yellow Bile, Melancholia= Black bile • 100-400AD “Acedia” (deadly sin= dejection, disgust, laziness) • 500AD Pope Gregory the Great defined Acedia as illness and not sin- 1st mental illness. • Robert Burton 1577-1640 1st Detailed study “Anatomy of Melancholy” • C19th to C20th Shift to “Depression” as more Physiological... “ a rut in the ground an economic term...a wimp of a word for such a major illness” Styron 1991

5. Global Burden of Disease according to disability life years lost (high income countries). Prince et al. Lancet 2007 Sept 8;370: 859-77

6. Should I blame the parents? • Childhood Relative Risk • Mum divorced 1.32 • Mum remarried 1.93 • Remarried with further conflict 3.42 • Childhood Sexual Abuse >4 • Loss of Parent Before age 11 taught in the past. Actually most kids cope with bereavement, but change in circumstances may have an effect. • However having one good relationship in childhood and high IQ is protective against adversity

7. Should I blame poverty? • Twice as common in the lowest social class. More likely to be persistent • Cause or Effect? Lorant et al. Am Journal of Epidemiology 2003

8. Should I blame life events? • 6 fold increase within 6 months of life event • “Top 5” Death of Spouse, Divorce, Separation, prison, death of family member------- ALL ABOUT LOSS! • 42% of recently bereaved spouses would fit criteria for depression at 12 months (Clayton and Darvish 1979) • Not everyone is as susceptible • Chronic social problems matter too! • Social Support is an important protective factor.

9. Should I blame physical illness? • Stroke: 20% (closer to frontal lobe-less depressed in left sided lesions!) • Parkinson's: 50% (more than other similarly disabling conditions) • Epilepsy:6-30% (10 times higher suicide rate than general population) • Persistent Pain: 30-54%More strongly associated with Central Pain (Fybromyalgia and IBS) than Peripheral Pain (R.A. or cartilage damage)). • Coronary Heart Disease 27% (Increased mortality post MI) • Cushing's but not thyroid disease.

10. But I’d Be Depressed with that lot!

11. Symptoms are easy to recognise but harder to define. • Depressed mood: different from sadness because of pervasiveness, intensity, duration • May be concealed • Anxiety • Agitation • Irritability • Anhedonia: the feeling of having lost feelings • Anergia • Retardation: 50% feel movements are slowed • Impaired concentration • Loss of interest • Disturbed sleep • Loss of libido Nothing Subjective there then!

12. First start by looking for it? • Are you depressed? • Do you feel down or hopeless? • Have you lost interest in things? If the answer is yes then • Review mental state. • Look for social functional and relationship problems PHQ 9 • 94% Sensitive 61% Specificity Spitzer et al

13. What to look out for • Past history of mood elevation • Chronic physical health problems • Previous response to treatment • Relationship problems • Social isolation and living conditions • Think about risk from the outset. • Agitation, Anxiety Suicidal ideation.

14. Depressive cognition, a disorder of thought. • Guilt and self reproach affects 75% of sufferers, worthlessness, responsible for their depression. • Disturbed judgement • Hypochondriacal ideas are often prominent • Future is hopeless, pessimism is central. • Sense of being (correctly) blamed...can extend into persecutory delusions. Mood congruent • OCD symptoms in 20-30%

15. Then seek to decide if the depression is mild, moderate or severe. • Mild: At least 2 weeks of low mood with some difficulty in continuing with ordinary social and work tasks • Moderate: More symptoms and Considerable difficulty continuing with social, work and domestic activities. (Usually with some somatic symptoms). • Severe: Considerable distress agitation or retardation. Guilt and very low self esteem to be expected. Most somatic symptoms seen. • Somatic symptoms: anhedonia, anergia, reduced reactivity, early morning wakening, psychomotor retardation, agitation, reduced appetite, weight loss, reduced libido.

16. For mild to moderate depression, treatment begins in primary care. • If also anxiety, treat the depression first. • Mind: Mindcasts podcasts. • Sleep hygiene: Royal College of Psychiatrists NorthumberlandMood juice • Active monitoring for mild/sub-threshold: Review in 2 weeks. Provide information. Contact the patient if they DNA. • Self help: Mind over Mood or Overcoming Depression.

17. Refer those with mild to moderate symptoms to IAPT for... • Guided self help on CBT principals. Could be computerised CBT • Group or even computer based CBT • Structured activity programme • Peer support.

18. CBT in a nutshell. fdfdsfwseesfes Nobody Likes Me Situation Sad Lonely Upset Situation Stay at home Situation Chest Tightness Nausea Situation

19. So when is there a role for medication? • Past history of moderate or severe depression • Sub-threshold symptoms for 2 years. • Severe Depression (alongside CBT)

20. Generic SSRIs should be the first line choice of medication. • Triple risk of GI bleeding especially alongside NSAIDs • Citalopram and Sertraline have fewer interactions. • Paroxetine has the worst discontinuation symptoms.

21. Head to head comparisons of antidepressants are few and far between. Better! Comparative efficacy and acceptability of 12 new -generation antidepressants. Andrea Cipriani. Lancet 2009; 373

22. Tricyclic antidepressants. • There is no role for Dosulipin(Dotheipin). Don’t use it! • Combining TCA and SSRI can cause an unpredictable increase in TCA plasma concentration. As much as four times! • Tricyclics have not been shown to improve sleep. Nor for that matter has Mirtazapine. • Leave a 4-7 day washout period when stopping Fluoxetine and starting TCA. The other SSRIs can be cautiously cross tapered. • Clomipramine worth considering if symptoms of OCD and Imipramine where panic symptoms are evident. both start 25mg and slowly increase to 150mg per day.

23. Other Antidepressants • Mirtazapine 15-45mg. Sedating-paradoxically more so at 15 than 45mg. Good as alternative to SSRI. In secondary care we sometime combine with SSRI • St Johns Wort: Hypericumperforatum • May be effective in mild/moderate depression. Unclear mechanism of action (MAO, NA, 5HT?) • Unlicenced. Can interact with other medication including OCP, digoxin, gliclazide, statins and Warfarin • Increased bleeding, hypersensitivity reactions, can precipitate mania • Active component can vary 50 fold between preparations

24. They’ve not recovered, so now what do I do? • Are they taking the tablets. • Switch to another AD. First off: another SSRI or Mirtazapine (NICE). I would include Venlafaxine in this list (up to 225mg). You can quickly switch from SSRI to SSRI (not so when other antidepressants are involved) • You could consider Tricyclic as an alternative • Imipramine (good for anxiety), Lofepramine- less toxic in overdose. Trazadone- Sedating. • More psychology: This time 16-20 sessions over 3-4 months (or more if needed to achieve remission)- High intensity IAPT NICE If that doesn’t work, you might start to think whether CMHT referral is warranted.

25. What would the CMHT do. • More CBT based work, IPT, Psychodynamic Psychotherapy, • Combination antidepressants, antipsychotics, Lithium, other mood stabilisers, ECT. • Work on psychosocial factors: Housing, benefits etc. • Manage Risks.

26. How long to Treat. • First episode: 6-9 months after full remission But 50-85% of patients will go on to have a second episode and 80-90% of these will go on to have a third. Forshall et al Psych Bullitin 1999 Treatment with Antidepressant reduces odds of relapse by 65%Glue p et al ANZJPsych 2010 • Second episode: Continue for at least 2 years

27. 10% of patients with major mood disorder will have a seasonal pattern SAD • A pattern of depression seen for over 2000 years. • 10% of patients with major mood disorder will have a seasonal pattern. • Popularised as SAD: depressive symptoms with some differences: hypersomnia, increased appetite with carbohydrate craving • Mostly mild to moderate severity • USA: Jan-Feb, Europe: Nov-Dec • Prevalence of up to 10% USA (3% Europe) esp northern latitudes • 2/3 will report improvement after 5 years.

28. Phototherapy for SAD SAD • 10,000 lux for 30 mins • Early morning use more effective but can lead to jumpiness, headaches and nausea • Dawn Simulators can be an alternative • Clearly continue until Spring • Antidepressants may also help

29. Support Services • Depression Alliance: www.depressionalliance.org • Depression UK http://www.depressionuk.org/index.shtml • Samaritans 24-hour helpline: 08457 90 90 90  email: jo@samaritans.org  web: samaritans.org Freepost RSRB-KKBY-CYJK, Chris PO Box 90 90 Stirling FK8 2SA