Download Depression - NHS Education for Scotland

Pharmacy
Pharmaceutical Care of People
with Depression
Quality Education for a Healthier Scotland
Objectives
Pharmacy
 Provide an overview of the diagnosis and therapeutic
management of depression
 Identify key pharmaceutical care needs of this group
of patients
 Explore ways of positively impacting on the care of
this patient population
Quality Education for a Healthier Scotland
National Programme for Improving Mental Health and Well-being in Scotland
September 2003-2006
Key aims:
 Raise awareness and promoting mental health and
well-being
 Eliminate stigma and discrimination
 Prevent suicide
 Promote and support recovery
Quality Education for a Healthier Scotland
Pharmacy
Key Facts & Figures
Pharmacy
Life-time Prevalence: 1 in 2 women; 1 in 4 men
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30% of above with Major Depressive Illness
>80% treated in primary care
50-60% of patients respond to 1st line Treatment
25-30% placebo response in controlled trials
20-60% of patients respond to switching between class of
antidepressant or SSRIs
 37% of patients relapse within 1 yr. of remission in primary care
Quality Education for a Healthier Scotland
Depression - Diagnosis by DSM-IV criteria
At least five of the following symptoms (including either 1 or 2) for two weeks and
causing clinically significant distress or impairment in functioning –
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Depressed mood
Loss of interest or pleasure in almost all activities
Significant weight loss or gain, or change in appetite nearly every day
Insomnia or hypersomnia
Psychomotor agitation or retardation (observable by others)
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Diminished ability to think or concentrate, or indecisiveness
Recurrent thoughts of death or suicide
Quality Education for a Healthier Scotland
Pharmacy
Depression - At Risk Patients
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Adverse social circumstances
Drug and alcohol misuse
Physical illness
Hospitalised patients
Patients Rx musculoskeletal/CNS drugs
Postnatal women
Action:
refer cases of suspected undiagnosed depression
Quality Education for a Healthier Scotland
Pharmacy
Management
Options (alone or in combination)
 Psychotherapy
 Drug therapy
 Electro-Convulsive Therapy
Aims of treatment
 Remission of symptoms to the pre-morbid state
 Restoration of social and working capacity
 Reduced risk of relapse and recurrence
 Prevent suicide
Quality Education for a Healthier Scotland
Pharmacy
Choice of Antidepressant
“There are no clinically significant differences in efficacy
between TCAs and SSRIs.”
Geddes JR, Freemantle N et al
SSRIs versus other antidepressants for depressive disorder
The Cochrane Library , Issue No4, 2000
Oxford: update Software (Cochrane review)
Quality Education for a Healthier Scotland
Pharmacy
Factors Influencing Choice
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Prominent features of depression
Co-existing disease states
Interacting drugs
Previous response to therapy
Individual tolerability to side effects
Ability to comply – one daily dosing may be simpler
Age of patient
Risk of overdose
Pregnancy & breast feeding
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Generally SSRI 1st line but not indicated in mild depression
Quality Education for a Healthier Scotland
Pharmacy
Mechanisms
Pharmacy
Pre-synaptic Receptors: Control
the release of neurotransmitter
Drug
Post-synaptic
Receptors
Quality Education for a Healthier Scotland
Tricyclic Antidepressants (TCAs)
 All act on Serotonin and NA but in different proportions
 Also hit muscarinic, 1 receptors and histamine receptors – responsible for side
effects
 Some more toxic in overdose than others
 Reserved for 3rd – 4th line these days
Quality Education for a Healthier Scotland
Pharmacy
Selective Serotonin Re-uptake Inhibitors (SSRIs)
Serotonergic side effects
 GI – Nausea, vomiting, dyspepsia
 Central – dizziness, agitation, insomnia, headache
 Others – Dry mouth, sexual dysfunction, bleeding disorders, anorexia
or weight loss.
Usually 1st line agents
Useful for patients with physical problems as have good side effect
profile
Quality Education for a Healthier Scotland
Pharmacy
Monoamine Oxidase Inhibitors (MAOIs)
Pharmacy
Boost available monoamines by inhibiting breakdown by monoamine oxidase enzyme
(centrally & peripherally)
Irriversible inhibitors -Phenelzine, tranylcypromine, Isocarboxazid
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Consumption of tyramine rich foods or sympathomimetic agents results in hypertensive crisis –
dietary restrictions apply
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Must not be prescribed with other antidepressants – washout must be observed
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Risks in elective surgery
Reserved as 4th-5th line but useful in phobic patients or those with atypical hypochondriacal
or hysterical features
Reversible inhibitors –Moclobemide
- Dietary restrictions less necessary
Quality Education for a Healthier Scotland
Venlafaxine & Duloxetine
(SNRIs)
Pharmacy
Boost serotonin & NA levels by reuptake mechanism
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New monitoring guidelines for venlafaxine – baseline ECG and blood pressure. Not to be
used if cardiac risk factors present. ECG & BP monitoring on therapy.
Some evidence to support high doses (225mg) in treatment resistant depression. Still used
in secondary care. Associated with raised BP.
Side effects include nausea, insomnia, agitation, restlessness, ECG changes,
hypertension, withdrawal effects (even with missed doses)
Duloxetine does not have the same monitoring requirements but not much experience with it
yet
Quality Education for a Healthier Scotland
Mirtazapine (NaSSA)
Pharmacy
Noradrenergic and specific serotonergic antidepressant
 presynaptic 2 antagonist – increases NA and serotonin levels centrally
but post synaptically blocks 5HT2 and 5HT3 subtypes so there is a
specific action on 5HT1. Less sleep disturbance and less sexual
dysfunction
 Also histaminergic – responsible for sedation and weight gain
 Practically no anticholinergic effects and no cardiovascular effects
 Rarely blood dyscrasias
Quality Education for a Healthier Scotland
Reboxetine (NARI)
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Noradrenaline reuptake inhibitor (weak effect on 5HT)
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Side effects – insomnia, sweating, dizziness, urinary hesitancy
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Can be considered 2nd or 3rd line therapy as favourable side effect profile
Quality Education for a Healthier Scotland
Pharmacy
General Risks of Antidepressant
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All antidepressants can cause hyponatraemia (CSM warning)
All lower seizure threshold to some extent.
All can cause sweating
All can cause “switching” in bipolar patients
Discontinuation reactions can occur with all antidepressants, but are more
common in short half life agents regardless of class.
Combinations of antidepressants are potentially risky and should be used only
under specialist supervision.
Switching drugs should be carried out with care.
Quality Education for a Healthier Scotland
Pharmacy
The Role of the Pharmacist
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Reduce stigma by using a responsive pro-active approach
Be responsive to possibility of undiagnosed depression
Provide information about antidepressants
Promote concordance
Monitor and provide support to patient & carers
Identify adverse effects and interactions (including non-prescribed medication)
Discourage self diagnosis and treatment
Support people at risk of suicide
Quality Education for a Healthier Scotland
Pharmacy
Initial Prescription for Antidepressant
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Pharmacy
Reduce stigma - reassure patient depression is a common illness and most patients
recover
Emphasise lag period – side effects often present before benefit, encourage to persevere.
Discuss discontinuation reactions but reassure that medication is not addictive. Do not stop
abruptly.
For SSRIs ensure GP has discussed side effects – patient should report any increase in
suicidal thoughts or increase in agitation or anxiety (may be indicative of akathisia).
Discuss common side effects of any antidepressant.
Ensure patient aware of expected duration of treatment.
Result : Improved concordance, reduced potential for relapse.
Quality Education for a Healthier Scotland
Lack of Response/Switching
Pharmacy
Ensure adequate trial. Where some response a dose increase may be considered.
Usually switch to a different class is indicated, but can switch within a class in certain circumstances
Switching guidelines –
 In theory it is better to stop and washout one drug before starting another (must do this with
MAOIs)
 In practical terms this is rarely possible if patient is ill.
 Potential problems with cross tapering include – antidepressant discontinuation effects,
interactions between the 2 drugs e.g. some SSRIs increase TCA levels, serotonin syndrome
(potentially life threatening), cholinergic effects.
If in doubt – seek specialist advice!
Quality Education for a Healthier Scotland
Stopping antidepressants
If stopped abruptly discontinuation symptoms may include –
 Headaches, restlessness GI symptoms, flu like symptoms, abdominal cramps,
sleep disturbance, anxiety, agitation “electric shock” sensations (particularly with
SSRIs)
 Common with short half life drugs, rare with fluoxetine
To avoid problems –
 After < 8 weeks treatment withdraw over 1-2 weeks
 After 6-8 months treatment taper over 6-8 weeks
 After long term maintenance, reduce dose by 25% every 4-6 weeks.
Quality Education for a Healthier Scotland
Pharmacy
How to Identify and Meet the
Pharmaceutical Care Needs
Pharmacy
 Education checklist for first presentation or changes in dose or medication
 Pharmaceutical care needs assessment for depression to identify gaps in patient
knowledge, effectiveness, safety and compliance
 Implement as part of your own CPD or local project.
Quality Education for a Healthier Scotland