Depression & Antidepressants Fareed Bhatti Pennine VTS - November 2009.

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


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)


Withdraw, then start trazodone

— Withdraw, then start fluoxetine



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





— Withdraw and wait at least 1 week


Moclobemide 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

Depression & Antidepressants Fareed Bhatti Pennine VTS - November 2009.

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