Transcript Depression - My Surgery Website

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