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Depression 2008 A common GP consultation 10% of our pts, 80% managed in primary care Assessment Always HAD score/PHQ Always risk assessment Suicidal ideation (common to a degree) What has/would stop you? Drug/Etoh? Consider other diagnosis (viral, anaemia, endocrine) Arrange review Presentations Low mood Somatic symptoms and signs Anxiety Psychotic symptoms ‘My wife told me to come’ I’m a bit stressed Tired all the time Somatic Symptoms Loss of appetite Weight loss Insomnia/Hypersomnia Amenorrhea Low libido Psychomotor retardation/agitation Constipation Antidepressants-media slating 08 They don’t work anyway Meta analysis of 47 trials Overall antidepressants improved symptoms >placebo but very small diff No significant diff between antidepressants and placebo at moderate initial depression only in severe ‘there is little reason to prescribe antidepressants to any but the most severely depressed pts unless alternatives have failed’ Good reads http://www.youtube.com/watch?v=0QWM_ Kni6l0 The bell jar – sylvia plath Prozac Nation: Young and Depressed in America - A Memoir -Elizabeth Wurtzel Sadness vs. disease SIGN Watchful supportive waiting Sleep hygiene and anxiety advice Regular exericise (structured supervised 3x45-60mins weekly 12 wks Guided self help (cbt principles) Brief psychological therapies (6-8 sessions over 12 wks) cbt/prob solving/counselling Social support (befriending/telephone) Mild Depression BJGP 07 qualitative study, Pts often reject notion of medical cure and emphasize self management, they identified that the key priority for their GP was to listen. My 10 min consultation Listen, this may be all that is required This will take more than 10 mins Often the pt comes with this as hidden agenda Explain need for follow up Simple measures 1st (speak with friend/family/work) Exercise – Distraction + some evidence ?self help, BTB, websites, books Major depression in cases of major depression, antidepressants are a first line treatment irrespective of environmental factors. in acute milder depression at initial presentation: antidepressants not indicated support, education and simple problem solving patient should be monitored for persistence/worsening in persistent milder depression, a trial of antidepressants is recommended if milder depression with a history of major depression then consider antidepressants Biological theory Antidepressant drugs modify the levels of monoaminergic neurotransmitters in the brain. Serotonergic and Noradrenergic neurones innervate wide areas of the brain. Synaptic levels of monoamines, particularly serotonin, are thought to be decreased in depression. Common drugs tricyclic antidepressants serotonin-selective reuptake inhibitors noradrenergic and and specific serotonergic antidepressants Moderate-Severe in moderate to severe depression there is more evidence for the effectiveness of antidepressant medication selective serotonin reuptake inhibitor is the first choice drug - because SSRIs are as effective as tricyclic antidepressants and are less likely to be discontinued because of side effects antidepressant medication should be offered before psychological interventions antidepressants are as effective as psychological interventions, widely available and cost less careful monitoring of symptoms, side effects and suicide risk (particularly in those aged under 30) should be routinely undertaken, especially when initiating SSRI symptomatic improvement in depression by the end of the first week of use, and the improvement continues at a decreasing rate for at least 6 weeks Escitalopram Citalopram Fluoxetine Paroxetine Sertraline Depression and what else? OCD, general anxiety disorder, panic – paroxetine (seroxat) OCD, bulimia, PMT – fluoxetine (prozac) OCD, PTSD – sertraline (lustral) Panic, social anxiety disorder – escitalopram/citalopram (cipralex)(cipramil) SSRI side effects anxiety, panic attacks, nervousness tremor, insomnia, hypersomnia postural hypotension palpitations sexual dysfunction pruritus, rash, sweating, yawning nausea, vomiting, diarrhoea, dry mouth, anorexia increase in risk of gastrointestinal bleeding Major Side effects The 'Serotonin syndrome' consists of confusion, agitation, hyperreflexia, myoclonus, shivering, sweating, tremor, fever, diarrhoea and inco-ordination. This has been described as a possible adverse effect common to all selective serotonin reuptake inhibitors Suicide risk A systematic review has examined the association between suicide attempts and selective reuptake inhibitors (SSRIs). The authors concluded that: there was a documented association between suicide attempts and the use of SSRIs. However several major methodological limitations in the published trials My favourites 1st line- usually citalopram/fluoxetine (pct pref) Cardiac pts – sertraline Under 18, only fluoxetine (prob only spec px) Elderly, citalopram If SSRI fails, consider ?compliance ?duration ?dose increase to max, ?2nd line 2nd line agents Mirtazepine – good for sedation (often w gain) alphaadrenoceptor antagonist (increased central noradrenergic and serotonergic NT;s Venlafaxine – serotonin and noradrenaline reuptake inhibitor (no sedative/antimuscarinic s/es, caution cardiac disorders Duloxetine – inhibits reuptake of serotonin and noradrenaline (also used in stress incontinence) If 2nd line agents fail, consider refer