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
• What are the two screening
questions for depression in
(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
• 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
• 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):
• Paranoia • hallucinations typically derogatory auditory
• delusions e.g. delusions of worthlessness
Anxiety symptoms of depression
• phobic disorders
Severities of Depression
< 5 symptoms.
• Mild Depression :
Just above 5 with minor functional impairment.
Symptoms or functional impairment between mild
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
intervention - SSRI secondary care for
- Combination of both long term Rx and
Treatment of Persistent
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
- Initial presentation of PST > 2 years
- PST or mild depression persisting after other
Stepped Care Model
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
- 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
Should the antidepressants ever be put on patient’s repeat medication?
- 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
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.
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.
- 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
To: TCA Trazodone SSRI SSRI Mirtazapine Reboxetine Moclobemide Venlafaxine
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
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
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
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
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.
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
b) St John’s wort with light therapy.
c) Bereavement counselling.
d) Any combination of above.
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
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
▫ 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)