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Depressive Illness and Antidepressants. Guy Brookes Psychiatrist, Leeds MH Trust, CRHT. Content. What is Depressive Illness Principles of Treatment Medication Options Medication Problems Other treatments. What is Depressive Illness. Episode Recurrent problem Socially disabling

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depressive illness and antidepressants

Depressive IllnessandAntidepressants

Guy Brookes

Psychiatrist, Leeds MH Trust, CRHT

content
Content
  • What is Depressive Illness
  • Principles of Treatment
  • Medication Options
  • Medication Problems
  • Other treatments
what is depressive illness
What is Depressive Illness
  • Episode
  • Recurrent problem
  • Socially disabling
  • Endogenous / Reactive
key symptoms
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
what isn t depressive illness
What isn’t Depressive Illness
  • Adjustment Disorder
  • Dysthymia
  • Personality Disorders
  • Alcohol Problems
  • Dementia
how well do we treat it
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
mild depression
Mild depression
  • Anti depressants not Indicated
  • Education / Problem solving / Support / Exercise / Bibliotherapy
  • Monitor (may develop!)
general principles of treatment
General Principles of Treatment
  • Context – their life, home life
  • Usual self
  • Suicide / self harm risk
  • Patient’s beliefs
  • Common formulation
nice guidance
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.
being nice cont
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
when to use antidepressants
When to use Antidepressants
  • Mod / Severe Depressive Illness
  • Patient Education – appropriate level
  • Risk / Benefit
  • Delay ?
how do antidepressants work
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

principles of prescribing
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
how to choose an antidepressant
How to Choose an Antidepressant
  • Previous Response, Patient views
  • Efficacy
  • Side Effects
  • Safety
  • Co-morbidity / associated symptoms
  • Cost
  • Contra indications / Cautions
  • Familiarity
efficacy
Efficacy
  • c. 60% effective in short term
  • 2 – 6 weeks
  • Very little difference for first line
  • Life events not important
  • Compliance
  • Dual action drugs
effectiveness
Effectiveness
  • Single antidepressant – 50-65% respond
  • Switch – 90% respond
  • Relapse

Cont antidepressant 10-25%

Stop 50%

  • Response not well
side effects
Side Effects
  • Individual priorities
  • Less troublesome if aware
  • Linked with premature cessation
  • Drug Interactions
tricyclic antidepressants
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
ssri s
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
are all ssri s the same
Are all SSRI’s the Same?
  • Receptor affinity – benefits and problems
  • Half lives – starting, stopping, switching
  • Interactions
  • Licence
  • Tolerability / Safety
reboxetine nri
Reboxetine(NRI)
  • No direct serotonin effect
  • No sedation or sexual dysfunction
  • Insomnia, agitation, postural hypotension.
  • ?cognitive / motivation symptoms
venlafaxine snri
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
mirtazapine nassa
Mirtazapine(NaSSA)
  • Simple dose
  • Weight gain and sedation
  • Blood dyscrasias (?)
  • Little sexual dysfunction
  • May have increased efficacy
bap guidance
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)
how do you really choose
How do you Really Choose
  • Safety
  • Co morbidity
  • Let Patient decide
and if it doesn t work
And if it Doesn’t Work
  • Check: Diagnosis

Ongoing life events

Compliance

Adequate dose

slide28
Then: Increase Dose

Switch

Augment

Psychotherapy

slide29
ECT
  • NICE guidance
  • Side effects
  • Memory impairment

short /long term

monitor

if it does work
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
non drug options
Non Drug Options
  • CBT / Interpersonal Therapy / Problem Solving Therapy

Mild / Mod rather than severe

  • But not: Counselling

St John’s Wort

Self help

secondary care
Secondary Care
  • Complex formulation
  • Bipolar
  • Risks
  • Treatment Resistance / stuck
  • What do you want?
in bpad
In BPAD
  • Maximise mood stabiliser
  • ?Lamotrigine
  • Very cautious with antidepressants
  • Non-drug options
useful sites
Useful Sites
  • www.bap.org.uk (consensus statements)
  • www.nice.org.uk
  • www.mhra.gov.uk
  • www.rcpsych.ac.uk/mentalhealthinformation