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Transcript
Depressive Illness and Antidepressants Guy Brookes Psychiatrist, Leeds MH Trust, CRHT Content • • • • • What is Depressive Illness Principles of Treatment Medication Options Medication Problems Other treatments What is Depressive Illness • Episode • Recurrent problem • Socially disabling • Endogenous / Reactive Key Symptoms • • • • • • Low Mood*, Hopeless Anhedonia – no pleasure* Lack of Energy Disturbed sleep / diet / sex drive Anxiety / Agitation / Retardation Difficulty thinking – “How are you managing at work” • Reduced self worth / Guilt What isn’t Depressive Illness • • • • • Adjustment Disorder Dysthymia Personality Disorders Alcohol Problems Dementia How Well do we Treat it • Up to 50% not identified • Up to 50% still depressed after 1 yr • Detection not necessarily associated with better long term outcome Mild depression • Anti depressants not Indicated • Education / Problem solving / Support / Exercise / Bibliotherapy • Monitor (may develop!) General Principles of Treatment • • • • • Context – their life, home life Usual self Suicide / self harm risk Patient’s beliefs Common formulation NICE Guidance • For 18 yrs and over. • Physical, social and psychological assessment • Mild depression – “Watchful waiting” and defer antidepressants. • First line treatment SSRI. – advise withdrawal synd. (and agitation on starting) • If high suicide risk or under 30 yrs see after 1 week of starting. Otherwise 2 weeks. Being NICE cont. • If no response after 4 weeks switch.(partial response after 6 weeks) • Venlafaxine – start and supervise by specialist services (to review) • Cont antidepressant for at least 2 yrs if 2 or more episodes • For severe depression consider antidepressant and CBT concurrently • If relapsed despite antidepressant consider CBT • Cessation – over at least 4 weeks • Remember carers When to use Antidepressants • • • • Mod / Severe Depressive Illness Patient Education – appropriate level Risk / Benefit Delay ? How do Antidepressants Work? • • • • All increase availability of monoamine/s But delay! ? Abnormality in receptors ? Monoamine systems respond abnormally on a molecular level e.g.. BDNF Principles of Prescribing • • • • Effective Dose Discuss Illness and Drug with patient Review soon after (1-2 weeks) Check Efficacy, Compliance, Side Effects and Suicide Risk • Continue after Resolution How to Choose an Antidepressant • • • • • • • • Previous Response, Patient views Efficacy Side Effects Safety Co-morbidity / associated symptoms Cost Contra indications / Cautions Familiarity Efficacy • • • • • • c. 60% effective in short term 2 – 6 weeks Very little difference for first line Life events not important Compliance Dual action drugs Effectiveness • Single antidepressant – 50-65% respond • Switch – 90% respond • Relapse Cont antidepressant 10-25% Stop 50% • Response not well Side Effects • • • • Individual priorities Less troublesome if aware Linked with premature cessation Drug Interactions The Candidates Tricyclic Antidepressants • Dose titration • Fatal in Overdose • Problematic side effects associated with poor compliance • Physical illness • Sedation, Anti-chol, CVS, Sexual dysfunction, Weight gain, Memory, Postural hypotension. (NB timing) • Severe hospital Depression SSRI’s • • • • • Initial Agitation Withdrawal Effects Simple Doses Safer in OD Sertraline and Citalopram few interactions. Post MI and stroke, Epilepsy • Nausea, Anxiety, racing thoughts, Sexual dysfunction, Headache. Serotonin synd. • Co-morbid Anxiety / Obsessive symptoms Are all SSRI’s the Same? • • • • • Receptor affinity – benefits and problems Half lives – starting, stopping, switching Interactions Licence Tolerability / Safety Reboxetine (NRI) • No direct serotonin effect • No sedation or sexual dysfunction • Insomnia, agitation, postural hypotension. • ?cognitive / motivation symptoms Venlafaxine (SNRI) • • • • • • • Dose titration Initial agitation Withdrawal effects Sexual dysfunction, Nausea / GI, Hypertension. Cardiotoxicity, fatality More effective at higher doses NB MHRA 31/5/06 Mirtazapine (NaSSA) • • • • • Simple dose Weight gain and sedation Blood dyscrasias (?) Little sexual dysfunction May have increased efficacy BAP Guidance • • • • In majority antidepressants equally efficacious. SSRIs more likely to be given at effective dose. Newer antidepressants better tolerated than TCAs. Initial weekly contact associated with improved compliance and short term outcome. • Improved outcome by drug counselling but not leaflets alone. • NB Placebo response!!! • Continuation for 6 months halves relapse (same dose) How do you Really Choose • Safety • Co morbidity • Let Patient decide And if it Doesn’t Work • Check: Diagnosis Ongoing life events Compliance Adequate dose • Then: Increase Dose Switch Augment Psychotherapy ECT • NICE guidance • Side effects • Memory impairment short /long term monitor If it Does Work • Response, Remission, Recovery • Single Episode cont for at least 6 months (halves relapse) • Severe, Recurrent or Over 65 cont for 2yrs • Cont with therapeutic dose • Education regarding recurrence. Plan. • Ensure full recovery • 1/3-1/2 relapse in 12 months (most in first 4 months) • Cessation – advise risk of discontinuation symptoms. Reduce gradually – c. 4 weeks Non Drug Options • CBT / Interpersonal Therapy / Problem Solving Therapy Mild / Mod rather than severe • But not: Counselling St John’s Wort Self help Secondary Care • • • • Complex formulation Bipolar Risks Treatment Resistance / stuck • What do you want? In BPAD • Maximise mood stabiliser • ?Lamotrigine • Very cautious with antidepressants • Non-drug options Useful Sites • • • • www.bap.org.uk (consensus statements) www.nice.org.uk www.mhra.gov.uk www.rcpsych.ac.uk/mentalhealthinformation