Transcript Depressive Illness and Antidepressants

Depressive Illness
and
Antidepressants
Guy Brookes
Psychiatrist, Leeds MH Trust, CRHT
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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
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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
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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
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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
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Mod / Severe Depressive Illness
Patient Education – appropriate level
Risk / Benefit
Delay ?
How do Antidepressants Work?
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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
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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
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Previous Response, Patient views
Efficacy
Side Effects
Safety
Co-morbidity / associated symptoms
Cost
Contra indications / Cautions
Familiarity
Efficacy
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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
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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
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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?
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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)
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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)
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Simple dose
Weight gain and sedation
Blood dyscrasias (?)
Little sexual dysfunction
May have increased efficacy
BAP Guidance
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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
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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
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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
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www.bap.org.uk (consensus statements)
www.nice.org.uk
www.mhra.gov.uk
www.rcpsych.ac.uk/mentalhealthinformation