Depression & Antidepressants. Fareed Bhatti Pennine VTS - November 2009. Format of Presentation. Split into subgroups ….. ( if possible) 3 presenters About 15-20 minutes Covered Topics - New NICE guidelines for Depression(Oct 2009)
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Pennine VTS - November 2009
- 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!
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.
. 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
(Chocolates only for telling both!)
Symptoms of general low mood include:
Anxiety symptoms of depression include:
< 5 symptoms.
Just above 5 with minor functional impairment.
Symptoms or functional impairment between mild and severe.
Most symptoms, marked functional impairment.
between primary and secondary care for long term Rx and follow up
- High Intensity psychosocial intervention
- Combination of both
Low Intensity psychosocial intervention
Treatment of Persistent sub-threshold(PST) Depressive symptoms
. Not routinely but can consider antidepressant for
Low-intensity psychosocial interventions
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
-- Group-based CBT / Interpersonal therapy/ behavioural activation
– Individual CBT or
-- Behavioural couples therapy for selected patients
- Give choice
- Explore I,C &Es
- Discuss no addiction potential
- Shouldn't discontinue suddenly
- Need to continue beyond remission
- Safety netting and 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?
OR stop and change
OR upto 2 weeks addition of benzodiazepine
(according to symptoms and not for chronic anxiety).
- 2-4 weeks
check compliance & increase support
OR increase dose
OR switch antidepressant
Continue for another 2-4 weeks
& change antidepressant if inadequate response, SEs or patient choice.
- Patient choice
- 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.
- Higher toxicity risk in overdose except Lofepramine, so increase dose slowly.
- Dosulepin(TCA) –not recommended because of high risk of toxicity with OD.
Different SSRI or better tolerated newer generation drug
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
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.
Psychological interventions- CBT or mindfulness based CBT
- 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
Continue meds for
2 years and then review