Depression & by JYg1oM



                         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)
    - 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?
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

- 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
 • What are the two screening
   questions for depression in
   primary care?

 (Chocolates only for telling both!)

• 1. During the last month have you often been
  bothered by feeling down, depressed or
• 2. During the last month, have you often been
  bothered by having little interest or pleasure in
  doing things?
Question 2

 • Name any 7 symptoms that you
   would use to assess for
 Symptoms of general low mood include:   The somatic features of depression
 • sadness and tearfullness              include:
 • low self-esteem                       • loss of appetite
                                         • weight loss
 • guilt
                                         • constipation
 • pessimism                             • insomnia or hypersomnia
 • helplessness                          • amenorrhoea
 • hopelessness                          • low libido
 • apathy                                • psychomotor retardation or agitation
 • loss of interests
 • anhedonia                             Psychotic symptoms (severe
 • loss of concentration                 depression):
 • depersonalisation
 • Paranoia                              • hallucinations    typically derogatory auditory
                                         • delusions   e.g. delusions of worthlessness
 Anxiety symptoms of depression
 • tension
 • apprehension
 • phobic disorders
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
1. Assessment Principles-duration and severity with degree
   of impairment should also be considered.
2. Encompasses adults with chronic illnesses as well.
3. Sub threshold depression recognised and guidelines
4. Diagnostic criteria has been changed from ICD-10 to
   DSM-IV so psychosocial therapies can be matched to the
   illness more appropriately.
5. Clearer role of psychosocial interventions defined but
   implications for existing overstretched services.
6. More accountability for the psychosocial interventions.
7. Guidance for relapse prevention-talking therapies+
Treatment of Depression with Chronic Illness

                                - High Intensity         Collaborative care
  Low Intensity                 psychosocial
                                                        between primary and
  psychosocial                  intervention
  intervention                  - SSRI                   secondary care for
                                - Combination of both     long term Rx and
                                                              follow up

                  Treatment of Persistent
                   Depressive symptoms
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
Stepped Care Model
Psychosocial interventions
 Low-intensity psychosocial interventions
 • 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
 • Treatment for moderate depression
 • For patients with initial presentation of moderate depression and a chronic physical health
 • Preventing relapse of depression –some cases
 -- Group-based CBT / Interpersonal therapy/ behavioural activation

 – Individual CBT or
 -- Behavioural couples therapy for selected patients
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
 - 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
- 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.
- 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
                         Different SSRI or better
         SSRI            tolerated newer                  Another class
                         generation drug

To:                  TCA                   Trazodone            SSRI                SSRI                  Mirtazapine       Reboxetine           Moclobemide         Venlafaxine
                                                                (Citalopram,        (Fluoxetine)
TCA                  Cros s -taper         Ha l ve dosage       Ha l ve dosage      Ha l ve dosage        Cros s -taper     Cros s -taper        Wi thdraw a nd      Cros s -taper
                     ca uti ously          a nd a dd            a nd a dd SSRI,     a nd a dd             ca uti ously      ca uti ously         wa i t at l east    ca uti ously
                                           tra zodone, then     then s low          fl uoxetine, then                                            1 week              s tarting with
                                           s l ow withdrawal    wi thdrawal         s l ow withdrawal                                                                venl afaxine 37.5
                                                                                                                                                                     mg/da y
Trazodone            Cros s -taper         —                    Wi thdraw, then     Wi thdraw, then       Cros s taper      Wi thdraw, s tart    Wi thdraw a nd      Wi thdraw. Start
                     ca uti ously with                          s ta rt SSRI        s ta rt fl uoxetine   ca uti ously      reboxetine at        wa i t at l east    a t venlafaxine at
                     very l ow dosage                                                                                       2 mg twi ce a        1 week              37.5 mg/da y
                     of TCA                                                                                                 da y a nd
                                                                                                                            i ncrease
                                                                                                                            ca uti ously
SSRI                 Cros s -taper         Wi thdraw, then      —                   Wi thdraw, then       Cros s -taper     Cros s -taper        Wi thdraw a nd      Wi thdraw. Start
(Citalopram,         ca uti ously          s ta rt tra zodone                       s ta rt fl uoxetine   ca uti ously      ca uti ously         wa i t at l east    venl afaxine 37.5
                                                                                                                                                 2 weeks             mg/da y a nd
                                                                                                                                                                     i ncrease very
Paroxetine)                                                                                                                                                          s l owly
SSRI                 Stop fl uoxetine.     Stop fl uoxetine.    Stop fl uoxetine.   —                     Wi thdraw a nd    Wi thdraw, s tart    Wi thdraw a nd      Wi thdraw. Wait
(Fluoxetine)         Start TCA a t         Wa i t 4–7 days ,    Wa i t 4–7 days ,                         s ta rt           reboxetine at        wa i t at l east    4-7 da ys . Start
                     very l ow dosage      then s tart low-     then s tart SSRI                          mi rta zapine     2 mg twi ce a        5 weeks             venl afaxine at
                     a nd i ncrease        dos e tra zodone     a t l ow dose*                            ca uti ously      da y a nd                                37.5 mg/da y.
                     very s l owly                              a nd i ncrease                                              i ncrease                                Increase very
                                                                s l owly                                                    ca utiously                              s l owly

Mirtazapine          Wi thdraw, then       Wi thdraw, then      Wi thdraw, then     Wi thdraw, then       —                 Wi thdraw, then      Wi thdraw a nd      Wi thdraw, then
                     s ta rt TCA           s ta rt tra zodone   s ta rt SSRI        s ta rt fl uoxetine                     s ta rt reboxetine   wa i t for 1 week   s ta rt
                                                                                                                                                                     venl afaxine
Reboxetine           Cros s -taper         Cros s -taper        Cros s -taper       Cros s -taper         Cros s -taper     —                    Wi thdraw a nd      Cros s -taper
                     ca utiously           ca utiously          ca utiously         ca utiously           ca utiously                            wa i t at l east    ca utiously
                                                                                                                                                 1 week
Moclobemide          Wi thdraw a nd        Wi thdraw a nd       Wi thdraw a nd      Wi thdraw a nd        Wi thdraw a nd    Wi thdraw a nd       —                   Wi thdraw a nd
                     wa i t 24 hours       wa i t 24 hours      wa i t 24 hours     wa i t 24 hours       wa i t 24 hours   wa i t 24 hours                          wa i t 24 hours
TCA, tri cycl i c a ntidepressant; SSRI, selective s erotonin reuptake inhibitor.
* Ci tal opram 10 mg/day; s ertraline 25 mg/day; or pa roxetine 10 mg/day.
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
 What would you suggest
 a) Sertraline.
 b) St John’s wort with light therapy.
 c) Bereavement counselling.
 d) Any combination of above.
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
   antidepressants            Thinking about stopping?
                              - Is it recurrent illness
     Remission                - Any residual symptoms or
      achieved                - Continuing psychosocial /physical
                               health problems
                                                                                    Psy chological interventions-
                                                                                     CBT or m indfulness based
       Cont inue Meds for 6                                                                     CBT
       more mont hs same

                                           Significant risk of relapse
                                           OR                                              Continue m eds for
                                           Hx of Recurrent depression                       2 y ears and then
                                                                                                  rev iew

        ▫   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)
The End

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