Treatment for Depression
Frederick Troncales, MD PGY 1 – internal medicine Brown University/MHRI
What are the Stats related to Depression? Lifetime risk of Major Depression is 712% in men and 20-25% in women 6.7 percent of the population, or about 14.8 million American adults, will struggle with depressive illness 80% of depressed people are not currently having any treatment
More Depression Stats
15% of depressed people will commit suicide Depression will be the second largest killer in 2020 after heart disease- and it has been shown to be contributory to fatal heart disease ( WHO 2001) Depression results in more absenteeism than almost any other physical d/o costing $51 Billion per year in lost productivity
What is the pathophysiology of Depression?
It has not clearly been defined Clinical and preclinical trials suggest disturbance in CNS serotonin activity. Other neurotransmitters implicated include NE and dopamine Clinical experience indicates a complex interaction between NT availability, receptor regulation and sensitivity and symptoms of MDD
How do I diagnose Depression? DSM IV
*Depressed mood most of the day, particularly in the morning *Markedly diminished interest or pleasure in almost all activities nearly every day (anhedonia); these can be indicated by the subjective account or observations by significant others Significant weight loss or gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or guilt Impaired concentration, indecisiveness Recurring thoughts of death or suicide
Symptoms should be present daily or for most of the day, or nearly daily for at least two weeks. Must cause clinically significant distress or impairment in functioning Not due to the direct effects of a substance (eg, drug abuse or medications) or a medical condition (eg, hypothyroidism) Do not occur within two months after the loss of a loved one A history of a prior manic episode in addition to these criteria suggests the diagnosis of bipolar disorder.
How do I evaluate somebody with depression?
Patients should have History, PE, and limited laboratory testing completed to rule out secondary medical causes Should be screened for Bipolar Disorder Assess for the presence of suicidal / homicidal ideation Assess if they have access to means of suicide
Presence of Psychotic symptoms, command hallucinations, severe anxiety Presence of alcohol and substance abuse
PHQ - 9
Allows measurement of diagnosis and severity of major depression Can monitor response to treatment To guide titration of antidepressant medication or response to psychotherapy
What can I say to somebody who’s depressed?
Many patients are reluctant to accept a diagnosis of depression Maybe important to stress that Depression is common Frequently assoc. with fatigue, headache, abdominal pain It is a physical illness assoc with biologic changes in the brain including depletion of key chemicals called catecholamines
Treatment with either medication or psychotherapy generally shortens the course and diminishes symptoms such as fatigue, poor self esteem, etc..
How can I improve my patient’s compliance to Medications? Patients should be told
Do not stop medications without talking to doctor There is LAG of 2-3 weeks before medications will relieve most symptoms S/E occur frequently during first few days but are gone after a week
What are the different Antidepressants?
Major Classes
SSRI TCA Heterocyclics (Bupropion) MAO Inhibitor Meds that inhibit both NE and Serotonin reuptake – Venlafaxine and Duloxetine
All available antidepressants appear to work via 1 or more of the following mechanisms:
(1) presynaptic inhibition of uptake of 5-HT or NE; (2) antagonist activity at presynaptic inhibitory 5-HT or NE receptor sites, thereby enhancing neurotransmitter release; (3) inhibition of monoamine oxidase, thereby reducing neurotransmitter breakdown.
How effective are antidepressants?
Studies concluded that antidepressants have a 50-60% response rate in the primary care setting
Which antidepressant should I use?
Number of clinical studies and reviews have concluded that clinical outcomes, quality of life outcomes and overall treament costs provide no clear guidance on choice Most compelling reason SSRI are used as 1rst choice in primary care is lower severity of S/E and less danger with overdose
What are the Side Effects?
How do I start antidepressants?
Starting at low doses can minimize the side effects of anitdepressants
Paroxetine 5-10 mg / day Sertraline 12.5 to 25 mg / day Fluvoxamine 25 mg /day Escitalopram 10 mg / day Citalopram 20 mg / day
Give for a week then gradually titrate up to full doses Usually taken in the morning
For the first 8-12 hours can be stimulating and may disturb sleep
How do I follow up?
Patients need to check in every 2 weeks for 68 weeks during initiation phase of medication treatment Initial therapeutic response typically occurs w/in 2 – 6 weeks
More than half of eventual responders begin to respond by week 2 Little evidence to support extending antidepressant therapy beyond 6 weeks in patients who have shown no response to maximal therapy
What do I do if patient does not respond?
If there is no response by 8 – 12 weeks at a maximum therapeutic dose…
Patient should be given a second trial of another antidepressant (same or different class) Patient’s antidepressant meds can be augmented with second drug such as Bupropion or Buspirone May refer to a psychiatrist
What could possibly cause treatment resistance?
Only 50% of patients in primary care respond to first choice of antidepressant 20% stop medication due to S/E 30% have no response Evaluate patient for chronic social stressors than can limit response to txt
Panic d/o, PTSD, Marital discord, childhood adversity, alcohol/substance abuse
Undiagnosed Bipolar d/o
How long should I treat?
Antidepressant medication taken at least 6-9 months Inform patient that medication leads to a genuine change in underlying neurochemistry It takes weeks to adjust to being on/off Should be tapered off to minimize s/e
Are Antidepressants safe in Pregnancy?
As with other drug use during pregnancy, decision to treat depends upon balance of risks and benefits Placebo controlled trial done on Fluoxetine, TCA showed no difference in risks of developing major fetal malformations, low IQ scores, behavioral devt There maybe some adverse effect on fetus yet to allow a woman suffer from symptomatic depression during pregnancy can also result in unacceptable costs to mother and the fetus
What do we do then?
Mild to moderate depressed pregnant patients
Should be treated with psychotherapy
Severely depressed pregnant patients or those unresponsive to psychotherapy should receive pharmacotherapy
SSRI’s are pregnancy category C
Do patients relapse?
Relapse is relatively common once patients with major depression stop txt 2 major risk factors for relapse
Persistence of subthreshold depressive sx’s 7 months after initiation of antidepressant txt History of 2 or more episodes of MD for 2 years
What do we do with patients that relapse?
Maintainance antidepressant txt can decrease rate of relapse AHPCR Guideline Panel recommended maintainance therapy for patients w/ a history of 3 or more depressive episodes and those with 2 depressive episodes plus risk factors that increase recurrence risk
What is Electric Convulsive Therapy?
Highly effective in pt w/ psychotic depression Effective for patient w/ severe melancholic depression on maximum medical therapy Meta-analysis of randomized trials concluded that ECT is an effective therapy for depression and is probably more effective than pharmacotherapy Decision for should be made with Psychiatrist Role of Primary care provider is to address patient’s fears and emphasize that the often quick response and low side-effect profile make it one of the most effective txt
“It seemed like this was one big Prozac nation, one big mess of malaise. Perhaps the next time half a million people gather for a protest march on the White House greens, it will not be for abortion rights or gay liberation…. but because we’re all so BUMMED out.”
Elizabeth Wurtzel Author
THANK YOU