Depression by zhanzhan0815



Dr Maryam Naeem
 GPST2 Psychiatry
•   RCGP Learning outcomes
•   Diagnostic criteria
•   NICE guidelines
•   AKT questions
   RCGP Curriculum statement 13:
  Care of people with mental health
• Risk factors for mental health problems, the
  difference between depression and emotional
• Diagnostic criteria for people experiencing
  mental health problems
• How to screen for mental illness, using
  effective and reliable instruments
       RCGP Learning outcomes
• Specific interventions and guidelines for
  individual mental health conditions

• Principles of mental health promotion

• Sufficient knowledge of the Mental Health Act
      Depression in primary care
• Prevalence 5-10% in primary care

• Ranks 4th as cause of disability worldwide

• Suicide 2nd leading cause of death in persons
  aged 20-35 years

• 2/3 of patients meet criteria for another
  psychiatric disorder (anxiety, substance misuse,
  alcohol dependency, PD)
Symptoms needed to meet criteria for
    ‘depressive episode’ ICD-10
• Group A symptoms

Depressed mood
Loss of interest and enjoyment
Reduced energy and decreased activity
      Diagnostic criteria ICD-10
• Group B symptoms

 Reduced concentration
 Reduced self-esteem and confidence
 Ideas of guilt and unworthiness
 Pessimistic thoughts
 Ideas of self-harm
 Disturbed sleep
 Diminished appetite
       Diagnostic criteria ICD-10
• Mild: At least 2 of A + 2 of B
• Moderate: At least 2 of A + 3 of B
• Severe: All 3 of A + at least 4 of B

• The severity of symptoms and degree of
  functional impairment also guide classification
            Biological symptoms
•   Loss of emotional reactivity
•   Diurnal mood variation
•   Anhedonia
•   EMW
•   Psychomotor agitation or retardation
•   Loss of appetite and weight
•   Loss of libido
    Other subtypes depressive disorder
•   Atypical depression
•   Agitated depression
•   Postnatal depression
•   SAD
•   Premenstrual dysphoric disorder
      Depression screening tools
• PHQ-9


• Becks inventory


            NICE Guidelines
   Key priorities for implementation
1) Screening in primary care and general hospital

2) Watchful waiting

3) Antidepressants in mild depression

4) Guided self help

5) Short term psychological treatment
               NICE Key priorities
• 6) Prescription of an SSRI

• 7) Tolerance and craving, and discontinuation/withdrawal

• 8)Initial presentation of severe depression

• 9)Maintenance treatment with antidepressants

• 10)Combined treatment for treatment resistant depression

• 11) CBT for recurrent depression
    Treatment of mild depression
• Watchful waiting

• Sleep & anxiety management

• Exercise

• Guided self-help

• Computerised CBT
     Treatment of mild depression-
       Psychological interventions
• Consider psychological treatment specifically
  focused on depression
Problem solving therapy
Brief CBT
• 6-8 sessions over 10-12/52
• Where significant co-morbidity exists ,
  consider extending treatment duration
  Drug treatment mild depression
• ‘Antidepressants are not recommended for
  the initial treatment of mild depression,
  because the risk-benefit ratio is so poor’

• Persistent symptoms – SSRI

• Mild depressive episode in those with a hx of
  moderate or severe depression - SSRI
   Treatment of moderate to severe
• ‘In moderate depression, offer antidepressant
  medication routinely, before psychological

• Delay in onset of effect

• Risk assessment – See those considered high
  risk of suicide and <30 1/52 post initiation,
  limit quantity prescribed
   Treatment of moderate to severe
         depression - SSRIs

Antidepressant, anxiolytic, amti-obsessive and
  anti-bulimic effects
• 5HT2 agonism
Agitation, akithisia, anxiety/panic, insomnia,
  sexual dysfunction
• 5HT3 agonism
Nausea, GI upset, diarrhoea, headache
    Treatment of moderate to severe
          depression - SSRIs
• As effective as TCAs and less likely to be discontinued
  beacuse of SEs

• Generic – Fluoxetine or citalopram

• Consider toxicity in overdose in patients at significant
  risk of suicide

• Highest risk TCAs (except lofepramine)

• Venlafaxine more dangerous than other equally
  effective drugs
    Treatment of moderate to severe

• If increased agitation develops early in
  treatment with an SSRI, provide appropriate
  information and, if the patient prefers, either
  change to a different antidepressant or
  consider a brief period of concomitant
  treatment with a benzodiazepine followed by
  a clinical review within 2 weeks.
              St Johns wort
• May be of benefit in mild to moderate

• Should not be prescribed or advised –
  uncertainty OTC potencies and liver enzyme
      Failure of 1st line treatment
• Consider switching to another anti-depressant if no
  response after 4/52

• If partial response, a decision to switch can be
  postponed until 6/52

• Treatments such as dosulepin, phenelzine, combined
  antidepressants, and lithium augmentation of
  antidepressants should be routinely initiated only by
  specialist mental healthcare professionals (including
  General Practitioners with a Special Interest in Mental
              2nd line treatment
• Choice for a 2nd antidepressant include a different SSRI
  or Mirtazapine

• Alternatives include:
 Moclobemide
 Reboxetine
 Lofepramine

• Consider other TCAs (except dothiepin) and
  venlafaxine, especially for more severe depression
     Stopping or reducing drugs
• Reduce doses gradually over a 4/52 period

• Warn about possible reactions:
• SSRIs – headache, nausea, paraesthesia,
  dizziness and anxiety

• Withdrawal of other antidepressants (esp
  MAOIs) - nausea, vomiting, headache, ‘chills’,
  insomnia, restlessness
Special considerations: Venlafaxine
• Increased likelihood of patients stopping
  treatment because of SEs

• Uncontrolled hypertension

• 300mg or more only under supervision or advice
  of psychiatrist

• Measure BP at initiation and during treatment

• Cardiac dysfunction
    Special patient characteristics
• Women – poorer toleration of imipramine

• Sertraline 1st choice in those with recent MI or
  unstable angina

• ECG and BP must be checked before starting a
  TCA in a patient at significant risk of CVD

• Venlafaxine and TCA contraindicated in those
  with recent MI or high risk serious cardiac
• Mild: Non-pharmacological

• Moderate-severe: SSRIs, different SSRI or
  Mirtazapine, Moclobemide, Reboxetine or

• Assess risk - Always ask directly about suicidal
               AKT Questions
• Which of the following is the most appropriate
  first line management for mild depression?

•   A) Citalopram
•   B) CBT
•   C) Fluoxetine
•   D) Paroxetine
•   E) Psychodynamic psychotherapy
               AKT Question 2
• Which one of the following is a risk factor for
  the development of depression?

•   A) Antisocial personality traits
•   B) Anxious/avoidant personality traits
•   C) High incidence of expressed emotion
•   D) Male sex
•   E) Paranoid personality traits
               AKT Question 3:
       Side effects of antidepressants
•   A) Amitriptyline
•   B) Citalopram
•   C) Fluoxetine
•   D) Lamotrigine
•   E) Mirtazepine
•   F) St Johns wort
•   G) Tryptophan
•   H) Venlafaxine
                AKT Question 3
• 1) Sedation and weight gain are common side effects

• 2) This antidepressant can cause a rise in anxiety levels
  during initial titration

• 3) BP should be monitored during initiation of this

• 4)EPSE can occur with this antidepressant

• 5)Caution should be exercised when choosing an
  antidepressant in a patient who is self-medicating with
Final Question...
• Thank you
• 1)Semple et al, Oxford Handbook Clinical
  Psychiatry, OUP 2005
• 2)NICE Summary PDF Depression 2007
• 3)Gelder et al, Shorter Oxford Textbook of
  Psychiatry, OUP 2008

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