Transcript Depression - Catterick & Colburn Medical Group

Depression
Key slides
What is depression?
NICE Full guideline CG90. October 2009
• Wide range of mental health problems characterised by
absence of a positive affect (lack of interest and anhedonia),
low mood, and a range of associated emotional, cognitive,
physical and behavioural symptoms
• What is ‘normal’?
• Major depressive illnesses identified by severity, persistence
of other symptoms and the degree of functional and social
impairment
• Consider duration, stage of illness and treatment history
What are the burdens of depression?
NICE Full guideline CG90. October 2009
• Mental and physical suffering
• Social impairments
– Inability to communicate
– Disturbed relationships
– Changes in social functioning
• Martial relationships and neglect of children
• Stigma
• Reduced self esteem / confidence
• Reduced working ability
• Exacerbation of pain and distress associated with physical
illness
• Economic burdens
What causes depression?
Shah PJ. Hosp Pharm 2002; 9: 219-22; Thompson
C. Medicine 2000; 28: 1-5
• Multifactorial and largely unknown
• Genetic predisposition
– 60% concurrence in twins
• Early childhood environment
– Lack of parental care or loss of mother?
• Social stress and life events
– Severe life events increase risk 6x in following 6 months
• Neuroendocrine changes
– eg HPA axis
• Neurochemical changes
– No single pathway
• Other diseases
• Drugs
What are some of the possible triggers for
depression?
WHO 1998
• Psychological
– Recent bereavement
– Relationship problems
– Unemployment
– Moving house
– Stress at work
– Financial problems
• Medications
– Antihypertensives
– H2 blockers
– Oral contraceptives
– Steroids
• Illness
– Infectious disease
– Chronic medical problems
– Alcohol abuse
– Substance abuse
• Other
– Family history
– Childbirth
– Menopause
– Seasonal changes
How common is depression in the UK?
NICE Full guideline 90
CKS Depression Nov 2007. www.cks.nhs.uk
• 5-10% consulting have major depression
• 130 per 1000 people
• 80 per 1000 (62%) consult their GP
• 49 out of 80 (61%) are subsequently not recognised
• 1 in 4 or 5 are referred to secondary care
• Dysthymia occurs in 1-4% of adults
Identification and assessment
NICE CG 90. Oct 2009
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Be alert to possible depression (particularly in those with
a past history of depression or a chronic physical health
problem with associated functional impairment) and
consider asking people who may have depression:
1. During the last month, have you often been bothered by
feeling down, depressed or hopeless?
2. During the last month, have you often been bothered by
little interest or pleasure in doing things?
– If “yes” to either: follow-up (Whooley and Simon.
New Engl J Med 2000;343:1942–50)
Identification and assessment
NICE CG 90. Oct 2009 NICE Full Guideline 90. Oct 2009
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Confirmation requires more detailed clinical
assessment; consider using a validated measure e.g.
PHQ-9, HDRS, BDI
Comprehensive assessment should not rely solely on
symptom count. Consider:
– Degree of impairment and/or disability
– Duration of episode
Always ask a person with depression directly about
suicidal ideas and intent.
PHQ = Patient Health Questionnaire
HDRS = Hamilton Depression Rating Scale
BDI = Beck Depression Inventory
Diagnosis of major depression by DSM-IV
Williams, et al. JAMA 2002;287:1160–70;
NICE CG 90. Oct 2009; Gruenberg AM, et al. 2005
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Depressed mood
Loss of interest or pleasure
(anhedonia)
Insomnia or hypoinsomnia
Appetite or weight change
Fatigue or loss of energy
Increased/decreased psychomotor
activity
Guilt or feelings of worthlessness
Suicidal ideation
At least 1 of X should be present
Major depression (5 symptoms)
Minor depression (2–4 symptoms)
 2 weeks
Categories of severity from DSM-IV
NICE CG 90. October 2009
• Subthreshold
– < 5 symptoms
• Mild
– Few if any symptoms in excess of the 5 required and
resulting in only mild functional impairment
• Moderate
– Symptoms or functional impairment between mild and
severe
• Severe
– Most symptoms and they significantly interfere with
functioning
Management of depression
The stepped care model
NICE CG 90. Quick Reference Guide Oct 2009
Antidepressants for duration of illness + at least 6 months
NICE Step 2: persistent subthreshold depressive
symptoms or mild to moderate depression (1)
NICE CG 90. Oct 2009
• Consider offering low intensity psychosocial interventions:
– Individual guided self-help based on cognitive behavioural therapy
(CBT) principles
– Computerised cognitive behavioural therapy (CCBT)
– A structured physical activity programme
• Choice of intervention should be guided by the patient’s preference
• Group CBT may be offered for those who decline low-intensity treatments
• Offer advice on sleep hygiene, if needed
• Monitor
– those judged to recover without a formal intervention
– those with subthreshold depressive symptoms who request an
intervention.
Using antidepressants for persistent subthreshold
depressive symptoms or mild to moderate depression
NICE CG 90. Oct 2009
Antidepressants
• Not recommended for the routine treatment of persistent
subthreshold depressive symptoms or mild depression
because the risk-benefit ratio is poor
• Consider them for people with
– Past history of moderate or severe depression
– Initial presentation of subthreshold depression that
has been present for a long period (typically >2 years)
– Subthreshold depressive symptoms or mild depression
that persists after other interventions.
NICE Step 3: persistent subthreshold depressive symptoms or mild to
moderate depression with initial inadequate response; or moderate and
severe depression
NICE CG 90. Oct 2009
Options
• Antidepressant (normally SSRI), or
• High intensity psychological intervention
– CBT (group or mindfulness-based)
– Interpersonal Therapy (IPT)
– Behavioural activation
– Behavioural couples therapy, or
• A combination of antidepressants and high-intensity psychological intervention
(CBT or interpersonal therapy) if moderate or severe depression
Choice depends on patient’s preference, duration of episode, trajectory of
symptoms, previous illness course and treatment response, likelihood of
adherence to treatment, likely side effects.
Which antidepressant?
NICE CG 90. October 2009
• SSRIs
– Equally effective as other antidepressants
– Have a favourable risk-benefit ratio
• Note:
– Increased risk of GI bleeding
– Higher risk of drug interactions with fluoxetine, fluvoxamine and
paroxetine
– Higher risk of discontinuation symptoms with paroxetine
• Consider toxicity in OD for those with significant suicide risk
– Venlafaxine associated with greater risk of death in OD
– TCAs (except lofeapramine) associated with greatest OD risk
• Discuss drug choice with patient
• Do not prescribe dosulepin
Drugs other than SSRIs
NICE CG 90. October 2009
• Need to consider…..
• Likelihood of discontinuation due to side effects with
venlafaxine, duloxetine and TCAs
• Cautions, contraindications and monitoring required
– Duloxetine and venlafaxine exacerbate hypertension
– Higher doses of venlafaxine may exacerbate arrhythmias
and need to monitor BP
– TCAs may cause postural hypotension / arrhythmias
– Mianserin needs haematological monitoring in elderly
• Non-revesible MAOIs eg phenelzine normally only prescribed
in secondary care
• Do not prescribe dosulepin
What should you discuss with the patient?
NICE CG 90. October 2009
• Explore their concerns and give a full explanation including:
– Gradual delay in onset of full effect
– Take as prescribed and continue for 6 months after
remission
– Information on potential side effects
– Potential for interaction with other medicines
– The risk and nature of discontinuation symptoms
(especially if drug has a shorter half-life eg paroxetine and
venlafaxine
– Addiction does not occur
• During the initial treatment stages there is a potential for:
– Agitation
– Anxiety
– Suicidal ideation
• Be vigilant of mood changes, negativity or hopelessness
especially during high-risk periods
• When the illness is severe or persistent information and
support should be offered to the carer
What about St John’s wort?
• May be of benefit in mild to moderate depression, but do not
prescribe because of:
– Uncertainty about appropriate dose and persistence of
effect
– Variation in the nature of the preparation
– Potential serious interactions with other drugs (eg OCP,
anticoagulants and anticonvulsants)
• Inform patients of these issues and the different potencies
available
How should you follow up patients?
NICE CG 90. October 2009
• If no increased risk of suicide
– See after 2 weeks
– Then regularly (eg every 2-4 weeks for 1st 3 months)
– Longer intervals thereafter if good response
• If <30 years or increased risk of suicide
– See after 1 week
– See frequently until risk not considered significant
• If no improvements after 2-4 weeks on 1st drug check
adherence
• After 3-4 weeks if response is absent / minimal consider:
– Increasing dose
– Switching antidepressant
• If some improvement by 4 weeks, continue for another 2-4
weeks
– If response inadequate consider switching drugs
How long should you continue medication?
NICE CG 90. October 2009
• At least 6 months after remission
• Explain:
– This greatly reduces the risk of relapse
– Antidepressants aren’t associated with addiction
• Review with patient need to continue longer than 6 months.
Consider:
– Number of previous episodes
– Presence of residual symptoms
– Other health problems
– Psychosocial difficulties
• For patients at risk of relapse, continue for at least 2 years
How should you stop or reduce dose of
antidepressants?
NICE CG 90. October 2009
• Slowly over a 4 week period (some may need longer)
• Due to long half-life no need with fluoxetine
What should you do if patients do not
respond to initial treatment?
NICE CG 90. October 2009
• Check adherence and any side effects
• Increase frequency or appointments and assessments
• Options
– Reintroduce previous treatments that have been
inadequately delivered or adhered to
– Increase the dose
– Switch to an alternative antidepressant
– Combine drugs (consult with a psychiatrist)
Switching drugs
NICE CG 90. October 2009
• The evidence for the relative advantage of switching either within
class or between classes is weak
• Reasonable choices for 2nd antidepressant
– Initially a different SSRI or better tolerated newer generation
SSRI
– Subsequently switching to an antidepressants that may be less
well tolerated eg venlafaxine, a TCA or an MAOI
• Caution with switching
– From fluoxetine to other antidepressants
– From fluoxetine or paroxetine to a TCA
– To a new serotonergic antidepressant or MAOI
– From a non-reversible MAOI
Combining drugs
NICE CG 90. October 2009
• Only start in primary care in consultation with a psychiatrist
• Consider adding:
– Lithium
– An antipsychotic (eg aripiprazole, olanzapine, quetiapine
or risperidone none licensed for depression in the UK
– Another antidepressant (eg mianserin or mirtazapine in
augmenting)
‘Augmentation treatment’
NICE CG 90. October 2009
• Not recommended routinely
• Antidepressant + benzodiazepine >2 weeks
– Risk of dependence
• Antidepressant + busiprone / carbamazepine / lamotrigine /
valproate / pinodol / thyroid hormones (none licensed in UK
for depression)
– Insufficient evidence
How might you ensure safety in prescribing?
NICE CG 90. October 2009
• Monitor symptoms and side effects eg anxiety, agitation,
mood changes and suicide risk (especially if <30 years),
particularly when initiating treatment and warn of possibility
• If high suicide risk:
– Limit prescription quantity
– Consider additional support (primary care staff or
telephone contact)
• Monitor for relapse and discontinuation / withdrawal
symptoms when reducing or stopping medication
• If not at risk of suicide see after 2 weeks, thereafter every 2-4
weeks in the 1st 3 months
• Continue for at least 6 months after remission
• Consider interactions with other drugs
• Consider specific cautions, contraindications and monitoring
requirements
• Non-reversible MAOI normal prescribed by specialist
• Dosulepin not recommended
• Do not initiate 2 drugs together in primary care unless
advised by a consultant
When should you refer?
NICE CG 90. October 2009
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Severe depression
Moderate depression and complex disorders
Significant risk of self-harm
Psychotic symptoms
Those requiring complex multiprofessional care
When depression fails to respond to various strategies for
augmentation and combination treatments
• Where an expert opinion on treatment and management
required
Which non-drug treatments are
recommended?
NICE CG 90. October 2009
Low intensity psychosocial interventions
• Individual guided self-help based on cognitive behavioural
therapy (CBT) principles
• Computerised cognitive behavioural therapy (CCBT) Beating
the Blues www.beatingtheblues.co.uk and MoodGYM
www.moodgym.anu.edu.au
• A structured physical activity programme
High intensity psychological interventions
• CBT (group or mindfulness-based)
• Interpersonal Therapy (IPT)
• Behavioural activation
• Behavioural couples therapy
Others
• Counselling
• Short-term psychodynamic psychotherapy
• Group-based peer support programmes is a low-intensity
option for those with chronic physical health problems
Case study 1
• Working through this case study will help you to:
• Review your practice relating to the identification and
assessment of people with possible depression
• Prioritise treatment for people who present with mild
depression
• Advise patients who start treatment with an antidepressant
• Mrs C is a 53-year-old woman presenting with symptoms of
irritability, low mood and feeling that she cannot cope. She
has been experiencing these symptoms for the past month,
but has been reluctant to bother you about them
• She has been experiencing family problems with her husband
and children for the last several months. She has asthma, but
she denies that this is problematic at the moment. She has
previously smoked 20 cigarettes per day and managed to stop
six months ago. Now she feels so low that she has started
smoking again, although she says she can't really afford to
• She accepts that she hasn't been getting out of the house
much recently when her family have asked her to go out with
them, but adds that she is less active during the winter
months anyway; she often prefers to stay in and watch
television. Her husband has commented that she is drinking
more alcohol than normal
• A friend had recommended that she takes St John's wort for
her mood and she has been for the last few weeks. She says
that she hasn't noticed any significant change, but feels more
anxious about her life and wants to know what can be done
to help
List the possible triggers for Mrs C's
symptoms of depression?
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Recent bereavement
Relationship problems
Unemployment
Moving house
Stress at work
Financial problems
Family history of depression
Menopause
Seasonal changes
Over use of alcohol and / or corticosteroids
• At her last appointment, which was over one year ago for
treatment of her asthma, it was noted that Mrs C had not
been using her inhalers in the correct manner and the clinical
records show that the she was less communicative than
normal
• What two questions could have been asked at the time to
help identify depression?
What two questions could have been asked
at the time to help identify depression?
• During the last month, have you often been bothered by
feeling down, depressed or hopeless?
• During the last month, have you often been bothered by little
interest or pleasure in doing things?
• If Mrs C answers "yes" to either question, she may be
depressed and further assessment is needed
• Adding in the question "Is this something with which you
would like help?" to the two screening questions for
depression, improves the specificity of the two question
approach in general practice, i.e. it helps to rule IN the
diagnosis of depression and is less likely to give a false
positive result
• If Mrs C answers "no" to both questions, this does not
necessarily always exclude depression; further assessment is
necessary if depression is still suspected
• Mrs C answers "yes" to both of these two questions
What further three questions do NICE recommend asking to
improve the accuracy of the assessment of depression in
people who have chronic physical health problems
• During the last month, have you often been bothered by
feelings of worthlessness?
• During the last month, have you often been bothered by poor
concentration?
• During the last month, have you often been bothered by
thoughts of death?
How should Mrs C be assessed further?
• Assessment should not rely simply on a symptom count, but it should take
into account both the degree of functional impairment and/or disability
associated with the possible depression and the duration of the episode
• The Patient Health Questionnaire, the Hamilton Depression Rating Score
or the Beck Depression Inventory should be considered
• NICE recommends that patients with depression are always asked directly
about suicidal ideas and intent, and that help is arranged that is
appropriate to their level of risk
• The updated 2009 NICE guidelines (CG90 and CG91) decided to adopt
DSM-IV for diagnosis of depression in adults rather than ICD-10, which
was used in the previous guideline
• Using a validated measure of severity, Mrs C appears to have
mild depression. She hasn't previously been diagnosed with
depression
What treatment options you would
recommend?
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People with mild depression should usually be offered one or more low-intensity
psychosocial interventions initially
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These include:
– Individual guided self-help based on the principles of cognitive behavioural therapy
(CBT)
– Computerised CBT (CCBT)
– Structured physical activity programme
•
The effectiveness of counselling in managing depression is uncertain and so it is
now only recommended as an option for Mrs C, if she declines other more
established treatments
•
Antidepressants aren't recommended for the routine treatment of mild
depression because the risk-benefit ratio is poor. However, they may be
considered where mild depression persists after other interventions
•
Although there is evidence that St John's wort may be of benefit in mild or
moderate depression
•
NICE recommends that practitioners should not prescribe or advise its use by
people with depression
•
There is uncertainty about the appropriate dose and persistence of effect,
variation in the nature of the preparations available and potential serious
interactions with other drugs (including oral contraceptives, anticoagulants and
anticonvulsants)
What would you do if Mrs C refused any
psychosocial treatment for her depression?
• NICE recommends that people with mild depression who do
not want an intervention should be assessed again, normally
within two weeks
• If they do not attend follow-up appointments, contact should
be made with them
• In addition, Mrs C should be given information about the
nature and course of her depression and the presenting
problems, and any concerns she may have about them should
be discussed. This is also recommended for patients who are
judged by the practitioner to recover without a formal
intervention
Mrs C mentions that she has had difficulty
sleeping recently. How would you advise her?
• Practical advice on sleep hygiene for Mrs C could include:
– Establishing regular sleep and wake times
– Creating a proper environment for sleep
– Taking part in regular physical activity
• In addition she has been drinking more alcohol than normal and has
started smoking again
• She should be advised to avoid drinking alcohol and smoking (along with
excess eating, if relevant) before sleep
• It would be helpful to reassure Mrs MC that insomnia is a common
symptom of depression, and this might improve with treatment
• Mrs MC chooses to try computerised CBT and regular physical
activity
• You follow her up regularly, but her depression symptoms
have not improved and after 6 weeks she returns to you
asking if she can try an antidepressant?
What other options could you offer her at
this stage?
• NICE recommends that patients with mild depression and an
inadequate response to initial treatments may be offered
either an antidepressant or a high-intensity psychological
therapy
• High-intensity psychological therapies include:
– CBT
– Interpersonal therapy (IPT)
– Behavioural activation
– Behavioural couples therapy
After explaining, and offering, a high-intensity non-drug
option to Mrs MC, she decides that she would still prefer to
try an antidepressant. What factors should influence the
choice of drug?
• Antidepressants have largely equal efficacy and so the choice
of drug should be largely dependent on:
– Side-effect profile
– Patient preference
– Previous experience of treatments
– Propensity to cause discontinuation symptoms
– Safety in overdose
– Interaction potential
• Normally an SSRI in generic form should be chosen as SSRIs
have a favourable risk-benefit ratio
When prescribing an antidepressant, what
advice would you give to the patient to help
with concordance?
• Good practice would be to explore any concerns the patient may have
about taking medication and give a full explanation of the reasons for
prescribing. Information to provide about taking antidepressants includes:
– The gradual delay in obtaining the full antidepressant effect
– The importance of taking medication as prescribed and the need to
continue treatment for at least 6 months after remission
– Information on potential side effects
– Potential for interactions with other medicines
– The risk and nature of discontinuation reactions (e.g. with shorter
half-life drugs such as paroxetine and venlafaxine) and how to
minimise them
– Addiction doesn't occur with antidepressants
• It is also worth advising the patient of the potential for increased
agitation, anxiety and suicidal ideation in the initial phases of treatment