Depressive Illness and Antidepressants

1. Depressive IllnessandAntidepressants Guy Brookes Psychiatrist, Leeds MH Trust, CRHT

2. Content • What is Depressive Illness • Principles of Treatment • Medication Options • Medication Problems • Other treatments

3. What is Depressive Illness • Episode • Recurrent problem • Socially disabling • Endogenous / Reactive

4. Key Symptoms • Low Mood*, Hopeless • Anhedonia – no pleasure* • Lack of Energy • Disturbed sleep / diet / sex drive • Anxiety / Agitation / Retardation • Difficulty thinking – “How are you managing at work” • Reduced self worth / Guilt

5. What isn’t Depressive Illness • Adjustment Disorder • Dysthymia • Personality Disorders • Alcohol Problems • Dementia

6. How Well do we Treat it • Up to 50% not identified • Up to 50% still depressed after 1 yr • Detection not necessarily associated with better long term outcome

7. Mild depression • Anti depressants not Indicated • Education / Problem solving / Support / Exercise / Bibliotherapy • Monitor (may develop!)

8. General Principles of Treatment • Context – their life, home life • Usual self • Suicide / self harm risk • Patient’s beliefs • Common formulation

9. NICE Guidance • For 18 yrs and over. • Physical, social and psychological assessment • Mild depression – “Watchful waiting” and defer antidepressants. • First line treatment SSRI. – advise withdrawal synd. (and agitation on starting) • If high suicide risk or under 30 yrs see after 1 week of starting. Otherwise 2 weeks.

10. Being NICE cont. • If no response after 4 weeks switch.(partial response after 6 weeks) • Venlafaxine – start and supervise by specialist services (to review) • Cont antidepressant for at least 2 yrs if 2 or more episodes • For severe depression consider antidepressant and CBT concurrently • If relapsed despite antidepressant consider CBT • Cessation – over at least 4 weeks • Remember carers

11. When to use Antidepressants • Mod / Severe Depressive Illness • Patient Education – appropriate level • Risk / Benefit • Delay ?

12. How do Antidepressants Work? • All increase availability of monoamine/s • But delay! • ? Abnormality in receptors • ? Monoamine systems respond abnormally on a molecular level e.g.. BDNF

13. Principles of Prescribing • Effective Dose • Discuss Illness and Drug with patient • Review soon after (1-2 weeks) • Check Efficacy, Compliance, Side Effects and Suicide Risk • Continue after Resolution

14. How to Choose an Antidepressant • Previous Response, Patient views • Efficacy • Side Effects • Safety • Co-morbidity / associated symptoms • Cost • Contra indications / Cautions • Familiarity

15. Efficacy • c. 60% effective in short term • 2 – 6 weeks • Very little difference for first line • Life events not important • Compliance • Dual action drugs

16. Effectiveness • Single antidepressant – 50-65% respond • Switch – 90% respond • Relapse Cont antidepressant 10-25% Stop 50% • Response not well

17. Side Effects • Individual priorities • Less troublesome if aware • Linked with premature cessation • Drug Interactions

18. The Candidates

19. Tricyclic Antidepressants • Dose titration • Fatal in Overdose • Problematic side effects associated with poor compliance • Physical illness • Sedation, Anti-chol, CVS, Sexual dysfunction, Weight gain, Memory, Postural hypotension. (NB timing) • Severe hospital Depression

20. SSRI’s • Initial Agitation • Withdrawal Effects • Simple Doses • Safer in OD • Sertraline and Citalopram few interactions. Post MI and stroke, Epilepsy • Nausea, Anxiety, racing thoughts, Sexual dysfunction, Headache. Serotonin synd. • Co-morbid Anxiety / Obsessive symptoms

21. Are all SSRI’s the Same? • Receptor affinity – benefits and problems • Half lives – starting, stopping, switching • Interactions • Licence • Tolerability / Safety

22. Reboxetine(NRI) • No direct serotonin effect • No sedation or sexual dysfunction • Insomnia, agitation, postural hypotension. • ?cognitive / motivation symptoms

23. Venlafaxine(SNRI) • Dose titration • Initial agitation • Withdrawal effects • Sexual dysfunction, Nausea / GI, Hypertension. • Cardiotoxicity, fatality • More effective at higher doses • NB MHRA 31/5/06

24. Mirtazapine(NaSSA) • Simple dose • Weight gain and sedation • Blood dyscrasias (?) • Little sexual dysfunction • May have increased efficacy

25. BAP Guidance • In majority antidepressants equally efficacious. • SSRIs more likely to be given at effective dose. • Newer antidepressants better tolerated than TCAs. • Initial weekly contact associated with improved compliance and short term outcome. • Improved outcome by drug counselling but not leaflets alone. • NB Placebo response!!! • Continuation for 6 months halves relapse (same dose)

26. How do you Really Choose • Safety • Co morbidity • Let Patient decide

27. And if it Doesn’t Work • Check: Diagnosis Ongoing life events Compliance Adequate dose

28. Then: Increase Dose Switch Augment Psychotherapy

29. ECT • NICE guidance • Side effects • Memory impairment short /long term monitor

30. If it Does Work • Response, Remission, Recovery • Single Episode cont for at least 6 months (halves relapse) • Severe, Recurrent or Over 65 cont for 2yrs • Cont with therapeutic dose • Education regarding recurrence. Plan. • Ensure full recovery • 1/3-1/2 relapse in 12 months (most in first 4 months) • Cessation – advise risk of discontinuation symptoms. Reduce gradually – c. 4 weeks

31. Non Drug Options • CBT / Interpersonal Therapy / Problem Solving Therapy Mild / Mod rather than severe • But not: Counselling St John’s Wort Self help

32. Secondary Care • Complex formulation • Bipolar • Risks • Treatment Resistance / stuck • What do you want?

33. In BPAD • Maximise mood stabiliser • ?Lamotrigine • Very cautious with antidepressants • Non-drug options

34. Useful Sites • www.bap.org.uk (consensus statements) • www.nice.org.uk • www.mhra.gov.uk • www.rcpsych.ac.uk/mentalhealthinformation