Transcript MAJOR DEPRESSION

THE PHILIPPINE COLLEGE OF
PSYCHOPHARMACOLOGY
2008
MAJOR DEPRESSION
(Featuring the LAPEL method)
TEACHING MODULE FOR THE
PRIMARY CARE PHYSICIANS
OBJECTIVES
• At the end of the module, the primary care
physician is expected to:
1. recognize the important features of major
depression using the LAPEL method
2. use appropriately the various antidepressant
drugs using the STEPS approach
3. apply these knowledge and skills with
confidence in his daily clinical practice
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FACTS ABOUT DEPRESSION
• Lifetime prevalence rate of 10 - 25% for
females and 5 - 12% for males
• Highest rates between 25 - 44 years old
• 1.5 - 3x greater risk in patients with a (+)
family history
• Probable cause: depletion of serotonin
and noradrenaline at the synapses
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Depression in Primary Care Setting
• 9% of patients in primary care settings
• 30% of acutely hospitalized adults
• 40% of older patients in long-term care
• 80% of severely depressed patients think
of suicide
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RISK OF SUICIDE
• The greatest risk in major depression
• Very important: always ask for suicidal
ideas/attempts; be wary of ‘smiling depressives’
• 15% in untreated patients; 4% among patients
with treatment
• 60% of patients talk about it before doing it;
never ignore even when it’s attention-seeking
• Men more successful than women (but more
women attempt it)
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MAJOR DEPRESSION : can be difficult to
diagnose in the primary care setting
A diagnostic tip:
• Patients who complain of vague, multiple,
non-physiologic, somatic complaints are
likely to have a depressive illness (socalled “masked depression”) or an anxiety
disorder
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Five questions to ask in a patient suspected
to have Major Depression
(The LAPEL Method – PCPsych 2006)
• Low mood (depressed, sad) *
• Anhedonia (loss of interest/pleasure) *
• Poor appetite (with weight loss)
• Early awakening (2-3 hours earlier)
• Low self-esteem (hopeless, guilty, suicidal)
* most important features
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LAPEL QUESTIONS
Low Mood
“Have you felt sad or depressed the last few
weeks? What part of the day you feel more
sad?”
Anhedonia
“Have you lost interest in things you used to
enjoy?
Poor appetite/weight loss
“How’s your appetite? Any weight loss?”
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LAPEL QUESTIONS
Early Awakening
“What time do you wake up in the morning? How
long before you sleep again?
Low self-esteem
“Have you felt hopeless recently? Do you feel
guilty about anything? Have you thought of
suicide at all? Any attempts?”
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LAPEL METHOD (PCPsych 2006)
• A positive response to three out of five
questions means the patient is most likely
depressed
96% sensitive*
94% specific*
• Two of the three positive responses should
be low mood and anhedonia (loss of
interest)
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(*Brody and Spitzer, 2002)
MAJOR DEPRESSION
• Treatment Strategies (including the
STEPS approach)
Antidepressants- TCAs, SSRIs, SNRIs /
NaSSA
Psychotherapy
Electro-convulsive treatment (ECT)
Combination Rx
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ANTIDEPRESSANTS
 The most important treatment
 Antidepressants increase levels of
serotonin and noradrenaline
 It takes about seven to 10 days for
antidepressants to take effect
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Using the STEPS Approach
1. TCAs - Tricyclic Antidepressants
Safety - unsafe in overdose cases
Tolerability- side-effects numerous
Efficacy- good to very good results
Price- greatest advantage; inexpensive
Simplicity- need 3x a day dosing
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Using the STEPS Approach
2. SSRIs - Selective Serotonin Reuptake
Inhibitors (drugs of choice)
Safety- no problem even in overdose
Tolerability- mainly GIT, mild/transient
Efficacy- good/very good
Price- most are pricey; some are not
Simplicity- once a day enough
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Using the STEPS Approach
3. SNRIs (Serotonergic and Noradrenergic
Reuptake Inhibitors)
NaSSA (Noradrenergic and Specific
Serotonergic Antidepressant)
Safety- same as SSRIs
Tolerability- NaSSA better than SNRIs
Efficacy- same as SSRIs; NaSSA earlier (?)
Price- more expensive than SSRIs
Simplicity- both SNRIs & NaSSA 1x/day
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USUAL DOSES OF ANTIDEPRESSANTS
•
• TCAs
Tofranil- 75-150mg/day; maintenance 75mg/day
Surmontil- 75-125mg/day; maintenance 75mg/day
• SSRIs
Zoloft or Serenata- 50mg/day; maintenance as is
Prozac or Adepssir- 20mg/day; as is
Lupram or Feliz– 20mg/day; as is
• SNRIs and NaSSA
Cymbalta- 60mg/day; as is
Remeron- 30mg/day; as is
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RESPONSE TO TREATMENT
• 70% - improvement with remission, on drug
treatment alone
• 30% - no improvement; combination Rx
needed
• 85% - improvement with antidepressants
combined with psychotherapy
• 90% - improvement with antidepressants +
ECT (selectively for the actively suicidal)
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DURATION OF DRUG TREATMENT
•
•
•
•
Varies from 6 months to 3 years
First episode usually for 6 months
Repeat episodes at least 1-2 years
Recurrent attacks (more than 5) about 3 - 5
years or longer
• Chronically depressed patients with suicidal
attempts + a family history of depression or
suicide may need indefinite treatment
• Problems of drug adherence a major worry
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SPECIAL PATIENT POPULATIONS
• Pregnant Patients
70% - report depressive symptoms
20% - postpartum depression
Use of antidepressants during pregnancy
reserved for the severely depressed
For the post-partum, may give
antidepressants but no breast feeding
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SPECIAL PATIENT POPULATIONS
• Children / Adolescents
No approved antidepressants for
patients < 18 years old
(exception: Tofranil for enuresis)
Lower doses are given, if at all (off label use)
Psychotherapy preferred
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SPECIAL PATIENT POPULATIONS
• Geriatric patients
High risk of suicide ( in patients with
chronic, painful, debilitating co-morbid
medical disorders)
Rule of thumb: start low, go slow
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Pharmacoeconomics of
Antidepressants (Mercury Drug February 2009)
• Tricyclic Antidepressants (TCAs)
Tofranil 25mg – P14.00 x 3-4
Surmontil 25mg – P16.60 x 3-4
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Pharmacoeconomics of
Antidepressants (Mercury Drug February 2009)
• Selective Serotonin Reuptake Inhibitors
(SSRIs)
Zoloft 50 mg – P119.50
*Serenata 50 mg – P59.00
Prozac 20 mg - P123.50
*Adepssir 20 mg – P43.75
Lupram 20 mg – P127.75
*Feliz 20 mg – P51.00
* bioequivalent
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Pharmacoeconomics of
Antidepressants (Mercury Drug February 2009)
• SNRIs and NaSSA
Cymbalta 60 mg – P196.75
Remeron 30 mg – P112.75
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Anxiolytics for Depression?
• Common choice among primary care
physicians, e.g. benzodiazepines
• Unfortunately, not effective; may also
cause dependence
• Remember: antidepressants can be
effectively and safely used for both
depression and anxiety; anxiolytics are
only effective in anxiety disorders.
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Antidepressant combined with Anxiolytic?
• A good strategy.
• Rationale: Antidepressants take 7-10 days
to take effect, anxiolytics almost
immediately.
• For example: may give Serenata 50
mg/day with Altrox (brand of alprazolam)
500 mcg/day. After 10-14 days, stop Altrox
and keep patient on Serenata.
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Anxiolytic with Antidepressant
 Many depressed patients are also anxious
(60%)
 It’s important to control the anxiety
symptoms early which are more disabling
than depressive symptoms
 Anxiolytics effect control quickly;
antidepressants take time
 Early control strengthens adherence
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SUMMARY
• The LAPEL method is a quick, highly sensitive,
and highly specific way to detect major
depression
• The STEPS approach shows that
antidepressants like SSRIs are safe, tolerable,
effective, priced reasonably, and simple to give
(drugs of choice)
• Antidepressants combined with psychotherapy
give best results
• ALWAYS ask about suicidal ideas/attempts
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THANK YOU VERY MUCH INDEED!
NOW, SMILE AND FIX YOUR LAPEL