Depression & Antidepressants Fareed Bhatti Pennine VTS - November 2009.
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DepressionDepression&&
AntidepressantsAntidepressants
Fareed BhattiPennine 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.
Costs: . 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!)
Answer
•1. During the last month have you often been bothered by feeling down, depressed or hopeless?
•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 depression?
AnswerSymptoms of general low mood
include: • sadness and tearfullness• low self-esteem• guilt• pessimism• helplessness• hopelessness• apathy• loss of interests• anhedonia• loss of concentration• depersonalisation• Paranoia
Anxiety symptoms of depression include:
• tension• apprehension• phobic disorders
The somatic features of depression include:• loss of appetite• weight loss• constipation• insomnia or hypersomnia• amenorrhoea• low libido• psychomotor retardation or agitation
Psychotic symptoms (severe depression):
• hallucinations typically derogatory auditory hallucinations
• delusions e.g. delusions of worthlessness
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 given.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+ meds.
Treatment of Depression with Chronic Illness
- High Intensity psychosocial intervention- SSRI- Combination of both
Low Intensity psychosocial intervention
Collaborative carebetween primary
and secondary care for long term Rx and follow up
Treatment of Persistent sub-threshold(PST)
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 interventions
Stepped Care Model
Psychosocial interventionsLow-intensity psychosocial interventions Indications:• 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 relapseTypes (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 interventionsIndications• Treatment for moderate depression• For patients with initial presentation of moderate depression and a chronic physical
health• Preventing relapse of depression –some casesTypes-- Group-based CBT / Interpersonal therapy/ behavioural activation– Individual CBT or-- Behavioural couples therapy for selected patients
Starting antidepressantsThe 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 supportOR increase doseOR switch antidepressant
Some improvementContinue for another 2-4 weeks
& change antidepressant if inadequate response, SEs or patient choice.
Choosing and changing antidepressantsChoosing:- Patient choice- SSRIs
- 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
Changing: SSRI
Different SSRI or better tolerated newer generation drug
Venlafaxine
TCAs
Another class
To: TCA Trazodone SSRI (Citalopram, Sertraline, Paroxetine)
SSRI (Fluoxetine)
Mirtazapine Reboxetine Moclobemide VenlafaxineFrom
TCA Cross-taper cautiously
Halve dosage and add trazodone, then slow withdrawal
Halve dosage and add SSRI, then slow withdrawal
Halve dosage and add fluoxetine, then slow withdrawal
Cross-taper cautiously
Cross-taper cautiously
Withdraw and wait at least 1 week
Cross-taper cautiously starting with venlafaxine 37.5 mg/day
Trazodone Cross-taper cautiously with very low dosage of TCA
— Withdraw, then start SSRI
Withdraw, then start fluoxetine
Cross taper cautiously
Withdraw, start reboxetine at 2 mg twice a day and increase cautiously
Withdraw and wait at least 1 week
Withdraw. Start at venlafaxine at 37.5 mg/day
SSRI (Citalopram, Sertraline, Paroxetine)
Cross-taper cautiously
Withdraw, then start trazodone
— Withdraw, then start fluoxetine
Cross-taper cautiously
Cross-taper cautiously
Withdraw and wait at least 2 weeks
Withdraw. Start venlafaxine 37.5 mg/day and increase very slowly
SSRI (Fluoxetine)
Stop fluoxetine. Start TCA at very low dosage and increase very slowly
Stop fluoxetine. Wait 4–7 days, then start low-dose trazodone
Stop fluoxetine. Wait 4–7 days, then start SSRI at low dose* and increase slowly
— Withdraw and start mirtazapine cautiously
Withdraw, start reboxetine at 2 mg twice a day and increase cautiously
Withdraw and wait at least 5 weeks
Withdraw. Wait 4-7 days. Start venlafaxine at 37.5 mg/day. Increase very slowly
Mirtazapine Withdraw, then start TCA
Withdraw, then start trazodone
Withdraw, then start SSRI
Withdraw, then start fluoxetine
— Withdraw, then start reboxetine
Withdraw and wait for 1 week
Withdraw, then start venlafaxine
Reboxetine Cross-taper cautiously
Cross-taper cautiously
Cross-taper cautiously
Cross-taper cautiously
Cross-taper cautiously
— Withdraw and wait at least 1 week
Cross-taper cautiously
Moclobemide Withdraw and wait 24 hours
Withdraw and wait 24 hours
Withdraw and wait 24 hours
Withdraw and wait 24 hours
Withdraw and wait 24 hours
Withdraw and wait 24 hours
— Withdraw and wait 24 hours
TCA, tricyclic antidepressant; SSRI, selective serotonin reuptake inhibitor.* Citalopram 10 mg/day; sertraline 25 mg/day; or paroxetine 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 depersonalisation.
What would you suggesta)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
▫ 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)
Started antidepressants
Remission achieved
Continue Meds for 6 more months
same dose
Significant risk of relapse ORHx of Recurrent depression
Continue meds for
2 years and then review
Thinking about stopping?- Is it recurrent illness- Any residual symptoms or- Continuing psychosocial /physical health problems
Augment meds if needed
Psychological interventions- CBT or
mindfulness based CBT
The End
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