depressive illness and antidepressants guy brookes psychiatrist, leeds mh trust, crht
TRANSCRIPT
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Depressive Illnessand
Antidepressants
Guy Brookes
Psychiatrist, Leeds MH Trust, CRHT
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Content
• What is Depressive Illness
• Principles of Treatment
• Medication Options
• Medication Problems
• Other treatments
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What is Depressive Illness
• Episode
• Recurrent problem
• Socially disabling
• Endogenous / Reactive
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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
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What isn’t Depressive Illness
• Adjustment Disorder
• Dysthymia
• Personality Disorders
• Alcohol Problems
• Dementia
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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
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Mild depression
• Anti depressants not Indicated
• Education / Problem solving / Support / Exercise / Bibliotherapy
• Monitor (may develop!)
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General Principles of Treatment
• Context – their life, home life
• Usual self
• Suicide / self harm risk
• Patient’s beliefs
• Common formulation
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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.
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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
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When to use Antidepressants
• Mod / Severe Depressive Illness
• Patient Education – appropriate level
• Risk / Benefit
• Delay ?
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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
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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
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How to Choose an Antidepressant
• Previous Response, Patient views• Efficacy• Side Effects• Safety• Co-morbidity / associated symptoms• Cost• Contra indications / Cautions• Familiarity
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Efficacy
• c. 60% effective in short term
• 2 – 6 weeks
• Very little difference for first line
• Life events not important
• Compliance
• Dual action drugs
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Effectiveness
• Single antidepressant – 50-65% respond
• Switch – 90% respond
• Relapse
Cont antidepressant 10-25%
Stop 50%
• Response not well
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Side Effects
• Individual priorities
• Less troublesome if aware
• Linked with premature cessation
• Drug Interactions
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The Candidates
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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
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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
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Are all SSRI’s the Same?
• Receptor affinity – benefits and problems
• Half lives – starting, stopping, switching
• Interactions
• Licence
• Tolerability / Safety
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Reboxetine(NRI)
• No direct serotonin effect
• No sedation or sexual dysfunction
• Insomnia, agitation, postural hypotension.
• ?cognitive / motivation symptoms
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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
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Mirtazapine(NaSSA)
• Simple dose
• Weight gain and sedation
• Blood dyscrasias (?)
• Little sexual dysfunction
• May have increased efficacy
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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)
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How do you Really Choose
• Safety
• Co morbidity
• Let Patient decide
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And if it Doesn’t Work
• Check: Diagnosis
Ongoing life events
Compliance
Adequate dose
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• Then: Increase Dose
Switch
Augment
Psychotherapy
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ECT
• NICE guidance
• Side effects
• Memory impairment
short /long term
monitor
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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
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Non Drug Options
• CBT / Interpersonal Therapy / Problem Solving Therapy
Mild / Mod rather than severe
• But not: Counselling
St John’s Wort
Self help
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Secondary Care
• Complex formulation
• Bipolar
• Risks
• Treatment Resistance / stuck
• What do you want?
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In BPAD
• Maximise mood stabiliser
• ?Lamotrigine
• Very cautious with antidepressants
• Non-drug options
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Useful Sites
• www.bap.org.uk (consensus statements)• www.nice.org.uk• www.mhra.gov.uk• www.rcpsych.ac.uk/mentalhealthinformation