Does Depression get you down?

Does Depression get you down?

Nick Venters Consultant Psychiatrist.

It’s very common, but perhaps not one in four of the population.

1 in 15 W0men. 1 in 30 men. (Metzer 1994)

You will each see 60 to 100 new cases a year in primary care

30000 workers in Britain believe they suffer from work-related stress, anxiety or depression(HSE 1995)

Costs the UK economy £3.4 Billion

One month prevalence rates worldwide show similar rates.

London 7%

Athens7.4%

Canberra 4.8%

USA 5.2%

Edinburgh 5.9%

Uslun and Sartorius 1993 WPA/PTD Educational Programme on Depressive Disorders

It’s been around a while. 400BC Hippocrates “The Nature of Man”

Mania=Yellow Bile, Melancholia= Black bile 100-400AD “Acedia” (deadly sin= dejection,

disgust, laziness) 500AD Pope Gregory the Great defined Acedia as

illness and not sin- 1st mental illness. Robert Burton 1577-1640 1st Detailed study

“Anatomy of Melancholy” C19th to C20th Shift to “Depression” as more

Physiological... “ a rut in the ground an economic term...a wimp of a word for such a major illness” Styron 1991

Global Burden of Disease according to disability life years lost (high income countries).

Prince et al. Lancet 2007 Sept 8;370: 859-77

Should I blame the parents?

Childhood Relative Risk Mum divorced 1.32 Mum remarried 1.93 Remarried with further conflict 3.42 Childhood Sexual Abuse >4

Loss of Parent Before age 11 taught in the past. Actually most kids cope with bereavement, but change in circumstances may have an effect.

However having one good relationship in childhood and high IQ is protective against adversity

Should I blame poverty?

Twice as common in the lowest social class. More likely to be persistent

Cause or Effect?

Lorant et al. Am Journal of Epidemiology 2003

Should I blame life events? 6 fold increase within 6 months of

life event▪ “Top 5” Death of Spouse, Divorce, Separation,

prison, death of family member------- ALL ABOUT LOSS! ▪ 42% of recently bereaved spouses would fit

criteria for depression at 12 months (Clayton and Darvish 1979)

Not everyone is as susceptible Chronic social problems matter too! Social Support is an important protective

factor.

Should I blame physical illness? Stroke: 20% (closer to frontal lobe-less depressed

in left sided lesions!) Parkinson's: 50% (more than other similarly

disabling conditions) Epilepsy:6-30% (10 times higher suicide rate than

general population) Persistent Pain: 30-54%More strongly associated

with Central Pain (Fybromyalgia and IBS) than Peripheral Pain (R.A. or cartilage damage)).

Coronary Heart Disease 27% (Increased mortality post MI)

Cushing's but not thyroid disease.

But I’d Be Depressed with that lot!

Symptoms are easy to recognise but harder to define. Depressed mood: different from sadness because of

pervasiveness, intensity, duration May be concealed

Anxiety Agitation Irritability Anhedonia: the feeling of having lost feelings Anergia Retardation: 50% feel movements are slowed Impaired concentration Loss of interest Disturbed sleep Loss of libido

Nothing Subjective there then!

First start by looking for it? Are you depressed? Do you feel down or hopeless? Have you lost interest in things?

If the answer is yes then Review mental state. Look for social functional and

relationship problemsPHQ 9 94% Sensitive 61% Specificity Spitzer et al

What to look out for

Past history of mood elevation Chronic physical health problems Previous response to treatment Relationship problems Social isolation and living conditions

Think about risk from the outset. Agitation, Anxiety Suicidal ideation.

Depressive cognition, a disorder of thought. Guilt and self reproach affects 75% of

sufferers, worthlessness, responsible for their depression.

Disturbed judgement Hypochondriacal ideas are often prominent Future is hopeless, pessimism is central. Sense of being (correctly) blamed...can

extend into persecutory delusions. Mood congruent

OCD symptoms in 20-30%

Then seek to decide if the depression is mild, moderate or severe. Mild: At least 2 weeks of low mood with some

difficulty in continuing with ordinary social and work tasks

Moderate: More symptoms and Considerable difficulty continuing with social, work and domestic activities. (Usually with some somatic symptoms).

Severe: Considerable distress agitation or retardation. Guilt and very low self esteem to be expected. Most somatic symptoms seen. Somatic symptoms: anhedonia, anergia, reduced

reactivity, early morning wakening, psychomotor retardation, agitation, reduced appetite, weight loss, reduced libido.

For mild to moderate depression, treatment begins in primary care.

If also anxiety, treat the depression first.

Mind: Mindcasts podcasts. Sleep hygiene:

Royal College of PsychiatristsNorthumberland Mood juice Active monitoring for mild/sub-

threshold: Review in 2 weeks. Provide information. Contact the patient if they DNA.

Self help: Mind over Mood or Overcoming Depression.

Refer those with mild to moderate symptoms to IAPT for...

Guided self help on CBT principals. Could be computerised CBT

Group or even computer based CBT Structured activity programme Peer support.

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CBT in a nutshell.

CBT

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Stay at home

Sad Lonely Upset

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Chest Tightness Nausea

So when is there a role for medication? Past history of moderate or severe

depression Sub-threshold symptoms for 2 years. Severe Depression (alongside CBT)

Generic SSRIs should be the first line choice of medication.

Triple risk of GI bleeding especially alongside NSAIDs

Citalopram and Sertraline have fewer interactions.

Paroxetine has the worst discontinuation symptoms.

Head to head comparisons of antidepressants are few and far between.

Better!

Comparative efficacy and acceptability of 12 new -generation antidepressants. Andrea Cipriani. Lancet 2009; 373

Tricyclic antidepressants.

There is no role for Dosulipin(Dotheipin). Don’t use it! Combining TCA and SSRI can cause an unpredictable

increase in TCA plasma concentration. As much as four times!

Tricyclics have not been shown to improve sleep. Nor for that matter has Mirtazapine.

Leave a 4-7 day washout period when stopping Fluoxetine and starting TCA. The other SSRIs can be cautiously cross tapered.

Clomipramine worth considering if symptoms of OCD and Imipramine where panic symptoms are evident.

both start 25mg and slowly increase to 150mg per day.

Other Antidepressants Mirtazapine 15-45mg. Sedating-paradoxically

more so at 15 than 45mg. Good as alternative to SSRI. In secondary care we sometime combine with SSRI

St Johns Wort: Hypericum perforatum▪ May be effective in mild/moderate depression. Unclear

mechanism of action (MAO, NA, 5HT?)▪ Unlicenced. Can interact with other medication including

OCP, digoxin, gliclazide, statins and Warfarin▪ Increased bleeding, hypersensitivity reactions, can

precipitate mania▪ Active component can vary 50 fold between preparations

They’ve not recovered, so now what do I do? Are they taking the tablets. Switch to another AD. First off: another SSRI or Mirtazapine

(NICE). I would include Venlafaxine in this list (up to 225mg). You can quickly switch from SSRI to SSRI (not so when other antidepressants are involved)

You could consider Tricyclic as an alternative Imipramine (good for anxiety), Lofepramine- less toxic in

overdose. Trazadone- Sedating. More psychology: This time 16-20 sessions over 3-4 months

(or more if needed to achieve remission)- High intensity IAPT NICE

If that doesn’t work, you might start to think whether CMHT referral is warranted.

What would the CMHT do. More CBT based work, IPT,

Psychodynamic Psychotherapy, Combination antidepressants,

antipsychotics, Lithium, other mood stabilisers, ECT.

Work on psychosocial factors: Housing, benefits etc.

Manage Risks.

How long to Treat. First episode: 6-9 months after full

remission

But 50-85% of patients will go on to have a second episode and 80-90% of these will go on to have a third. Forshall et al Psych Bullitin 1999

Treatment with Antidepressant reduces odds of relapse by 65%Glue p et al ANZJPsych 2010

Second episode: Continue for at least 2 years

10% of patients with major mood disorder will have a seasonal pattern

A pattern of depression seen for over 2000 years. 10% of patients with major mood disorder will

have a seasonal pattern. Popularised as SAD: depressive symptoms with

some differences: hypersomnia, increased appetite with carbohydrate craving

Mostly mild to moderate severity USA: Jan-Feb, Europe: Nov-Dec Prevalence of up to 10% USA (3% Europe) esp

northern latitudes 2/3 will report improvement after 5 years.

SAD

Phototherapy for SAD

10,000 lux for 30 mins Early morning use more effective but

can lead to jumpiness, headaches and nausea

Dawn Simulators can be an alternative

Clearly continue until Spring Antidepressants may also help

SAD

Support Services

Depression Alliance: www.depressionalliance.org

Depression UK http://www.depressionuk.org/index.shtml Samaritans 24-hour helpline: 08457 90 90 90 

email: [email protected] web: samaritans.org

Freepost RSRB-KKBY-CYJK, ChrisPO Box 90 90StirlingFK8 2SA