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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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depression antidepressants

Depression&Antidepressants

Fareed Bhatti

Pennine VTS - November 2009

format of presentation
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!

why is it important
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
question 1
Question 1
  • What are the two screening questions for depression in primary care?

(Chocolates only for telling both!)

answer
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?
question 2
Question 2
  • Name any 7 symptoms that you would use to assess for depression?
answer7
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
severities of depression
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.

new nice guidelines for depression salient points
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.
treatment of depression with chronic illness
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

important difference from previous guidance
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
psychosocial interventions
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

starting antidepressants
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?

drug titration
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.

choosing and changing antidepressants
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

question 3
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.
answer 3
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.

stopping antidepressants preventing relapse

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