Transcript Dealing with Depression in Rural Australia

Dealing
with Depression
Dealing with
Depression
in Rural Australia
in Rural Australia
Dealing with Depression
in Rural Australia
Black Dog Institute
Mission: To advance the understanding and management of the
mood disorders through
 Research
 Clinical Services
Clinical
Services
Research
 Community Support
 Education
Community
Support
Education
The Institute is partially funded by NSW Ministry of Health and philanthropic
support. No pharmaceutical companies have input to the program.
2
Introduction - Materials
Materials for you to keep…
Workshop Workbook 3 Sections
To be handed back…
 Evaluation form
 Reinforcing Activity within 2 weeks
 MAP registration form
For detailed information on GP Mental Health treatment items
please go to this link:
www.health.gov.au/mentalhealth-betteraccess
3
Housekeeping!
 Bathrooms
 Breaks
 Phones
 Adverse Feedback form
Accreditation - 40 QI & CPD Category 1 points
- 30 ACCRM PRPD points
- MHST
4
Learning Objectives
 Differentiate between the differing sub-types of clinical
depression
 Recognise the contribution of biological, social and
psychological factors to the current depressive episode
 Assess and manage risk in the depressed patient
 Select pharmacological treatment best suited to the individual
patient
 Develop a comprehensive mental health treatment plan
derived from the formulation of the depressive episode
5
Online Predisposing Activity
 Today’s workshop has been written to compliment the online
predisposing activity you have completed prior to attending
 The learning from the online Sub-typing Depression program
will be assumed in today’s workshop
 An overview of this material can also be found on the Black Dog
Institute website
6
The Experience of Depression
Introduction
Show Marty’s Story
What are the unique challenges/opportunities when managing
depression in a rural setting?
7
Introduction
Why spend a day talking about depression?
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Depression is common
 National Survey of Mental Health and Wellbeing 2007:
Mood disorders affected 6.2% of people aged 16-85 years (7.1%
of women and 5.3% of men) in the 12 month period surveyed
 In any one year up to one million adults are affected by
depression
 In 2004-5 overall depression rates were similar for urban and
rural areas
 However males aged 45-64 living in a non-urban setting were
1.4 times more likely to experience depression.
9
Depression is a common general
practice presentation
 BEACH (Bettering the Evaluation and Care of Health program):
psychological problems are treated in 11.5 of every 100 general
practice encounters, with depression being the most common
presentation.
10
Depression is disabling
 Depression, one of the leading causes of disability worldwide
 Depression associated disability costs the Australian economy
$14.9 billion annually
 More than 6 million working days lost each year
 Impacts on all relationships particularly within the family unit
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Depression is diverse:
a. Culture
@
Culture – 2011 - 25% of Australians were born overseas, 15% from
a non English background
What impact does cultural background have on the diagnosis and
management of depression?
 Affects how depression is experienced and expressed
 Affects personal meaning of the depression
 Affects help seeking behaviours
 Impact of language/use of translators
 Adherence to treatment
12
Depression is diverse:
b. Gender
Gender – Which gender is more likely to develop depression?
Why?
 Females
(1) Reporting bias
(2) Actual increased risk
13
Depression is diverse:
c. Age
Age - Which age groups are most likely to suffer from depression?
 Female incidence peaks in late adolescence
 Male incidence peaks in 35-45 age group
14
Depression is complex
@
Which co -morbidities are common with depression?
Psychiatric :
 Anxiety disorders
 Substance abuse
 Personality Disorders
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Depression is complex
Physical:
 Cancer - recent study confirming high rates of often undetected and
untreated depression in cancer patients
 Cardiovascular disease - high levels of depression in post AMI patient
- depression is associated with an increased risk of a
cardiovascular event
 Diabetes - increased prevalence of depression in diabetes
- depression increases risk of developing diabetes
 Chronic Pain
 Also a symptom of some illnesses such as MS, thyroid disease,
connective tissue disease etc.
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Today’s program
The aim of today’s program is not only to improve the ability
to diagnose clinically significant depression but also to
create more effective and meaningful treatment plans by:
 identifying the sub- type of depression involved
 developing a deeper understanding of the context within
which the depression has occurred
Topic 1
Assessment and Diagnosis
18
Learning Objectives
At the end of this topic you will be able to:
 Prioritise key objectives for the first consultation with a
depressed patient
 Undertake a comprehensive risk assessment
 Appropriately manage the suicidal patient
 Utilise the patient formulation as the basis of management
planning
 Delineate the role of stress and personality in presentations of
non-melancholic depression
 Use an appropriate outcome tool
 Provide psycho education best suited to the patient’s situation 19
Steve – aged 42
Meet Steve (play DVD)
As you observe this consultation note down any significant
information that may help you with your assessment and
management of Steve in your workbook.
20
Steve
 What are some of the key issues in Steve’s presentation?
(We will look at making a specific diagnosis shortly)
21
Steve
Steve has come in at the request of his wife.
What difficulties does this create?
 What expectations do you think Steve would have of this visit to
the GP?
 What would Steve think explains how he has been feeling?
22
What are your priorities?
7
In the first consultation with a depressed patient there are often
numerous issues that require the GP’s attention but limited time
to address them all.
What would issues would be some of your priorities for Steve’s
first visit?
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What are your priorities?
The “10 steps”
1.
Engage with Steve
2.
Make a diagnosis including sub-type
3.
Exclude other illness (as appropriate)
4.
Assess risk
5.
Complete a formulation / Mental Health Treatment Plan
6.
Provide psycho-education
7.
Decide whether medication is indicated
8.
Consider psychological therapies
9.
Foster support networks
10. Well being planning/relapse prevention
It will generally require several consultations to work through all
these priorities
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(1) Engage
 For many people with depression, the decision to see a health
professional has come after considerable deliberation and
hesitation
 Their experience of this first visit can shape their attitude
towards health care professionals for some time
 A negative experience may deter them from help seeking into
the future
 A positive experience may be the turning point in their
experience of living with depression
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Engagement strategies
@
What are the strategies that you use to engage the depressed
patient?
 An empathic style (i.e., demonstrating the ability to take the
patient's viewpoint)
 Letting the patient lead the interview
 Respecting the patient’s pace of delivery, especially when
slowed or having difficulty concentrating
 Responding to non-verbal cues
 Listening attentively
…continued
26
Engagement strategies
@
 Tolerating silences
 Maintaining eye contact
 Avoiding asking a stream of closed-ended questions (i.e.
Yes/No questions)
 Avoiding interrupting the patient
 Occasionally summarising and checking your understanding
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(2) Diagnosis (including sub-type)
Is Steve stressed or depressed?
What are the key features that need to be present in order to
diagnose clinical depression?
 Depressed mood
 Increased self-criticism
 Lowered self-esteem
 More than two weeks duration
 Functional impairment
In what domains is Steve experiencing functional impairment?
Is his functional impairment mild, moderate or severe?
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Diagnosis (including Sub-Type)
What sub-type of depression is Steve experiencing?
What are the features that define non-melancholic depression?
 Clinical depression where melancholic and psychotic features
are absent
 Residual group of depressions
 Diverse group coloured by personality style and stressors
 Identifying stressors and coping style are key to management
 Most common (90%) sub-type seen in primary care
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(3) Exclude other illness
 Are there any alternate or additional diagnoses to consider?
 What investigations (if any) would be helpful? Why?
30
Using the MAP
•
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Free service from the Black Dog Institute
Access by referral from mental health practitioners registered with BDI
Online testing and prompt and secure report delivery direct to the referring clinician
20 years research and development BDI
Available Australia-wide
Designed to be used in conjunction with clinical assessment
Identifies : depression severity
patient functionality
probability of bipolar disorder
depression sub-type
influence of anxiety
vulnerable personality type
influence of lifestyle and environmental factors
Supports treatment planning
Enhances communication within the treatment team
To register go to www.blackdoginstitute.org.au/healthprofessionals/map/overview.cfm 31
(4) Assessing Risk
 Assessing the risk of self- harm and suicide is an essential
component of any mental health consultation
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About Suicide
What has happened to the suicide rate in Australia over the last
decade?
 Decrease - from 13.2 per 100,000 in 1997 (2723 deaths ) to 11
per 100,000 in 2012 (2535 deaths) although has slightly edged
up from 2380 deaths in 2011
 What accounts for this change?
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About Suicide
Which gender is more likely to die by suicide?
 Males
What is the ratio of males to females completing suicide?
 2012 - Ratio of 3 :1
By what ratio are suicide attempts more common than
completed suicide?

Ratio of 30:1
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About Suicide
Which age group is most vulnerable?
 Statistics vary from year to year.
 In 2012:
males : Over 80s followed closely by 45 – 49 yr olds
females : Over 80’s followed closely by 50 - 54 yr olds
 In general, although suicide is responsible for one in five
deaths in the 15 -24 age group the suicide rate in adolescence
has dropped dramatically.
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About Suicide
@
What is the most common means of suicide in Australia?
In 2012:
 Hanging accounted for just over half of suicides (54.3%)
 Poisoning including over-dose 23%
 Firearms 6.8%
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Suicide in Rural Areas
 Australian Institute for Health and Welfare (2007) : men in
remotes areas 2.6 x more likely die by suicide than those in
metropolitan areas
 2005-2007 Queensland Suicide Register : higher rates of male
suicide in remote areas (36.32 per 100,000) compared to nonremote areas (18.25 per 100,000)
 Rates of male suicide higher in regional areas (21.81 per
100,000) than in non-regional areas (17.27 per 100,000)
 There were no significant risk differences for females
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Suicide Risk
@
What factors in a person’s history would make you consider them
to be at significant risk of suicide?
 Male
 Indigenous (22.4:100,000)
 Psychiatric Illness – 90% have mental health diagnosis, 60% with a
mood disorder
 Higher risk in melancholic and psychotic depression.
 Previous attempt
 Family history of suicide
 Exposure to the suicidal behaviour of others
 Chronic Illness
(cont……)
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Suicide Risk
@
 Isolated - “The more alone you are the more in trouble you
are”
 Severe hopelessness
 Access to means
 Alcohol/drug use
 Impulsive
 Aggressive, violent
 Unemployed
 Recent losses
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Suicide Protective Factors
@
What factors in a person’s history would reduce their risk of
suicide?
 Access to high quality mental health care
 Regular ongoing connection with a health service
 Restricted access to lethal means
 Strong connection to family and community support
 Good coping skills e.g. problem solving and assertiveness
 Religious beliefs that discourage suicide
Strengthening protective factors has an important role in suicide
prevention
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Discussion
@
What is it like for a person to experience suicidal ideation?
 May fear they are going crazy
 May fear they are dangerous to others
 May feel ashamed of their thoughts
 May begin to dwell on the suicidal thoughts giving them
increasing power
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About Suicide
How accurately can we predict someone’s risk of suicide?
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Steve’s Risk
On history alone how would you rate Steve’s level of risk of selfharm or suicide?
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Assessing Risk
Every patient with a depressive illness needs to be asked about
suicide
 What difficulties do you encounter when taking a suicide
history?
 Are there any drawbacks of taking a suicide history?
 How do you go about discussing suicide with your patients?
 What are some key phrases that you use?
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Suicide History
6
What are the key components of a suicide history?
 Ideation
 Intent
 Planning
 Means
 Previous attempts
 Protective factors
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Skills Practice
Form a group of 3 - clinician, Steve and observer.
The roles will rotate through the day - everyone will be the
clinician at some time
The clinician wishes to raise the issue of suicide with Steve and
assess his level of risk
If you are Steve: On page 77 in your workbook there is a guide for
as to how answer questions on this subject
Try and respond authentically to doctor rather than reading out
the answers
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Skills Practice
Observer :
 Note any useful questions and comments that encourage Steve
to open up and confide in the clinician
 Note any unhelpful questions and comments that discourage
Steve from confiding in the clinician
 In view of Steve’s responses, how do you now rate his risk of
self harm or suicide?
47
Managing suicide risk
7
How would you manage this in your practice?
(a) Involving family and friends:
Who would you involve in Steve’s care?
– How do you assess the capacity of friends/family to be involved
– How would you negotiate their involvement?
– How would this impact on your appraisal of the level of risk?
(b) Use of crisis teams and hospitalisation –
– What services are available in your area?
– When are these useful/when are they not useful?
…continued
48
Managing suicide risk
6
(c) Access to 24 hr support services – use of a crisis card
(d) Strengthening the therapeutic relationship
– Eliciting reasons to live
– Instilling hope
– Provide psycho-education and treatment for the underlying condition
Involving other professionals /services
– Frequent assertive review and monitoring – a directive approach to
follow up.
(e) Linking to other services
– What referrals would you make for Steve? When?
No evidence that safety contracts on their own act as a deterrent.49
Managing suicide risk
Helpful websites:
 www.suicidecallbackservice.org.au (crisis counseling 24/7)
(1300 659 467 )
 www.livingisforeveryone.com.au (health professionals and
consumers)
 www.square.org.au (health professionals)
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Priorities
So far we have:
1. Engaged with Steve
2. Made a diagnosis including sub-type
3. Excluded other illness
4. Assessed risk of suicide
Next we will continue with
5. Complete a formulation / Mental Health Treatment Plan
6. Provide psycho-education
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(5) Complete the Formulation
When taking a mental health history, it is often useful to organise
the information you elicit into a formulation.
This has four components often known as the 4 Ps
 Predisposing factors – factors that predate the depression
 Precipitating factors – factors that triggered the depression
 Perpetuating factors – factors that prevent the depression from
remitting
 Protective factors – factors that increase the likelihood of
recovery and decrease the likelihood of relapse
52
Formulation
 The formulation can be added to in subsequent sessions as new
information comes to light. It can then be used as a foundation
for the Mental Health Treatment Plan

A formulation grid can be helpful in organising the information
for management planning
 Exercise (in pairs) : Complete Steve’s formulation
(see grid on following
slide)
(Refer to Steve’s story on page 76)
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Steve’s Formulation
@
 Predisposing: anxious-worrier personality, high expectations of
self as man/provider, flood and drought, financial stress,
 Precipitating: wife working in town
 Perpetuating: insomnia, social isolation, alcohol, beliefs about
help-seeking
 Protective: caring partner, children, wife in employment
What is the value of completing the formulation for:
(a) Steve (b) the clinician
55
Formulation
Which factors in the formulation can be addressed in the
management plan?
 Predisposing: anxious-worrier personality, high expectations of
self as man/provider, flood and drought, financial stress,
 Precipitating: wife working in town
 Perpetuating: insomnia, social isolation, alcohol, beliefs about
help-seeking
56
Formulation
Which protective factors in the formulation can be drawn from
to assist in recovery?
 Protective: caring partner, children, wife in employment
57
Mental Health Treatment Plan
 There are many templates available for GP MHTP
 We have included the Department of Health and Aging
proforma in your work book
 How would your formulation assist in developing a MHTP
together with Steve?
 Let’s review the completed plan on page 18 of your workbook.
58
Stress and depression sub-types
Steve is currently facing numerous stressors
He also has an anxious worrier personality style
Non- melancholic depression arises from a combination of:
 Stressors and
 Personality vulnerabilities that may reduce resilience in the
face of stress
in varying measure
The personality style may also colour the presentation of the
depression e.g. an anxious worrier will present with an anxious
depression.
59
Stress in other depression sub-types
 In melancholic and psychotic depression, although a stressor
may be present it is not necessarily so
 The association with stressors appears to lessen over the years
and with subsequent episodes
 This means at times there will be no apparent trigger
60
Non-melancholic depression
In the assessment of non-melancholic depression it is therefore
necessary to identify:
1. Stressors (acute and chronic) and
2. Any ‘key and lock’ effect (see next slide)
3. Personality vulnerabilities
(1) We have listed Steve’s stressors in the formulation
61
(2) Stress and “Key and Lock”
 For some patients it is the enormity or nature of the stress that
overwhelms them rather than a lack of effective coping skills
that leads to depression
 For others it is the meaning they place on a stressor that
underpins their reaction to that stressor which to the observer
may seem out of proportion to the stressor
 This is often known as the “Key and Lock” Model
 Insight into the “key and lock” is helpful for patients in
understanding their own reaction to the stressor
Is there any “key and lock” effect that you can identify in Steve’s
story?
62
(3) Personality and non-melancholic
depression
What personality traits do you think would make a person
more likely to become depressed when stressed?
• Anxious Worrying
Social Avoidance
• Personal Reserve
Rejection Sensitivity
• Perfectionism
Self-criticism
• Irritability
Self-focused
•
Clearly there is considerable overlap of personality styles and one
person may have a number of these traits in varying measure
63
Personality and Temperament
The 109 item personality and temperament questionnaire
(TAPQ) can be completed on the BDI website.
 TAPQ is also incorporated into the MAP.
 Steve’s MAP report is in your workbook (page 20) (next
slide)
 Teaching Steve specific skills to manage stress and address his
personality vulnerabilities will both assist his recovery and
prevent relapse
 We will look at this in greater detail this afternoon
64
65
Coping well with stress
7
What coping skills are helpful in the face of increased stress?
 Eliciting support of others
 Prioritising
 Problem solving
 Assertive communication
 Time management
 Delegating
 Time for self and self-care
66
Impact of personality style on
coping with stress
@
How does Steve’s personality style effect his ability to cope with stress?
How do anxious worriers typically respond to stress?
 Autonomic arousal
 Ruminate and catastrophise
 Increased self doubt
 Become helpless
 Seek reassurance from others
 Use distraction, avoidance
 Improving skills for coping with stress will be discussed further in
management planning
67
(6) Psycho-education
a. Why is psycho-education important when managing patients
with depression?
b. What important messages do patients need at this early stage?
c. What resources do you commonly use for psycho-education in
your practice?
 Black Dog Institute website has printable fact sheets on a range
of issues of concern for people with depression and carers
 Psychological Toolkit for use by health professionals additional
resources
68
Psychological Toolkit
69
Psycho-education
(a) Outcome tools
 What is the role of using outcome tools in depressed patients?
 What outcome tools do you use in your practice?
 Which outcome tool would you use for Steve?
 Look at the completed DASS for Steve (Page 23 in workbook).
70
Using the Psychological Toolkit
(b) Mood chart
( page 25)

Would it be useful to give Steve a mood chart to complete?

What instructions would you give him?
71
Summary: Topic 1
The initial assessment of a depressed patient needs to include:
 Successfully engaging the patient
 Making a diagnosis of clinical depression including sub-type
 Assessing the patient’s level of risk to self and others
 Developing a formulation inclusive of personality style and
stressors
 Completing a Mental Health Treatment
 Using an outcome tool as a baseline for monitoring progress
 Psycho-education for patients and their families
72
The Carer Experience
Jessica’s Story / Carer presentation
 Discuss
73
Carer
Carers need:
 encouragement to acknowledge their own needs and reach out to be
supported themselves
 to negotiate communication pathways with health professionals
 to be pointed to resources such as books and websites to learn more
about depression and become more educated in their loved one’s
condition
 to maintain connection with the rest of the family, health
professionals, other carers and the wider community rather than risk
insularity
 to learn to delegate
…continued
74
Carer
 help to recognise priorities and organise tasks into a
manageable load
 help negotiating the system
 opportunities to vent and off load their frustrations and distress
 to adjust their own work load in response to the demands
placed on them eg. shorter hours or light duties at difficult
times
 to at times participate in exercise, stress management and
relaxation with the sufferer
 to balance being helpful with taking over and not allowing
space for the sufferer to regain autonomy and self esteem.
75
Topic 2
Management
76
Learning objectives
 Initiate antidepressant medication when pharmacological
treatment is warranted
 Effectively manage pharmacological treatment in the depressed
patient
 Select appropriate psychological strategies that most effectively
address stressors and personality sub – types.
 Assist patients in fostering an effective support network
 Recognise the importance of regular monitoring and review
consultations for the depressed patient.
77
Ellie
 Let’s listen to Ellie as she talks to her GP about how she has
been feeling
Meet Ellie 24 yrs (play DVD)
(script is also in your workbook)
Note down any significant information in the history and your
observations of Ellie in your workbook.
78
Ellie

What are the key issues in Ellie’s presentation?

What is the symptom that Ellie is complaining of?
Depression is common in primary care patients but many
people with depression do not openly present with mental
health concerns

What other presentations may indirectly alert you to the
possibility that a person may be suffering from depression?

How will that impact on the consultation?
79
Rural presentations
Australian Journal Primary Health July 2013
• 1375 rural men
• 212 in farming and agricultural occupations
“ almost half of the farming and agriculture group (48.0%) had
contact with a GP in regard to physical health issues in the
3 months before their death by suicide”
• average age of death 43
Figures are from Queensland Suicide Register which have recorded suicides in Qld since 1990
80
Ellie
In pairs discuss:
1. What would be the challenges engaging with Ellie? How would
you overcome these?
2. What is the diagnosis for Ellie?
3. What other diagnoses are possible?
How would you exclude these?
1. What is your level of concern for Ellie’s safety?
Discuss in larger group
81
Diagnosis (including sub-type)
What features of melancholic depression are evident in Ellie’s
presentation?
(1) Presence of psychomotor changes:
 Retardation
 Cognitive impairment (concentration, memory difficulties)
(Some melancholic depression will present with agitation rather
than retardation)
82
Diagnosis (including sub-type)
(2) Additional Features
 Loss of “light in the eyes”
 Mood and energy lowest in the morning
 Pervasive anhedonia
 Complete non-reactivity
 Profound anergia
 Early morning waking
83
Diagnosis
Psychomotor features become more observable with age.
In younger people these are more likely to be elicited in the
history than observed.
84
Diagnosis
Given Ellie’s age and presentation is there any other diagnosis we
need to consider?
 Melancholic depression in a younger person is moderately
suggestive of a bipolar disorder.
 80% of depression in bipolar illness is melancholic or psychotic.
What features in Ellie’s story are suggestive of a possible bipolar
disorder?
How would you explore this possibility?
85
What are the common features
of mania or hypomania?
A discrete period uncharacteristic of normal personality style
 Energised and wired
 Talk more and over people
 Spend more money
 Are indiscrete
 Require less sleep and do not feel tired
 Increased libido
 Creative and grandiose plans
 And can be irritable, argumentative or aggressive
86
Highs
What is the most significant difference between mania and
hypomania?
 Mania has psychotic features.
 Mania is consistent with a diagnosis of Bipolar 1
 Hypomania with a background of depressive episodes is
consistent with Bipolar 2
87
88
Self assessment test
89
Highs
Why is it important to distinguish whether Ellie has ever had a
“high”?
 Impact on management
 Impact on prognosis
90
Ellie
 Which outcome tool would you use for Ellie?
 Let’s look at Ellie’s completed DMI 10 in your workbook (pge 30)
 Is this information useful?
91
(7) Deciding on Medication
 Clearly medication is only one aspect of treating depression and
we will look at other modalities of treatment in the next unit.
Would you prescribe medication for Ellie? Why?
 The treatment of a melancholic depression always necessitates
the use of antidepressant medication
92
Medication - melancholic
 Which neurotransmitter pathway dysfunctions contribute to
melancholic depression?
 Therefore, which medication would you prescribe for Ellie?
 For a melancholic depression, a dual action antidepressant is
more likely to be effective than an SSRI
 However, in young people there may be some initial success
with an SSRI incurring a lower side effect burden
 This is less likely to be effective in future episodes
93
Medication - melancholic
 Broad spectrum antidepressants (such as tricyclic
antidepressants) are also effective in treating melancholic
depression but have a higher side effect burden
 With age, tricyclics antidepressants become increasingly more
effective than SSRIs so that by age 60 they are 4 times more
likely to be effective than an SSRI in successfully treating a
melancholic depression.
Given the degree of Ellie’s functional impairment it may be
reasonable to start with a dual action medication from the outset.
94
Medication - non - melancholic
Would you prescribe medication for Steve? Why?
 Only 50% of non-melancholic depression will respond to
medication
 Psychological therapies are the main stay of treatment
Consider medication when:
 Severe functional impairment
 Anxiety is a key symptom
 Previous response to medication
 Inadequate response to non-pharmacological treatment
95
Medication - non - melancholic
 Which neurotransmitter pathway dysfunction contributes to
non-melancholic depression?
 Therefore, which medication would you prescribe for Steve?
 There is generally no value in moving to broader acting anti-
depressants when treating non-melancholic
 It can be helpful to trial a second SSRI where the first has not
been helpful or side effects have been dose limiting
96
SSRIs
Which medications are in the SSRI class? (see also Antidepressant
Regimes section 3)
 Prozac/Lovan - Fluoxetine
 Aropax - Paroxetine
 Zoloft - Sertaline
 Luvox - Fluvoxamine
 Cipramil - Citalopram
 Lexapro - Escitalopram
97
Dual action antidepressants
@
Which medications are dual action antidepressants?
 Efexor - venlafaxine
 Pristiq - desvenlafaxine
 Cymbalta - duloxetine
 Avanza - mirtazapine
98
Broad Spectrum antidepressants
Which medications are broad spectrum antidepressants?
 Tricyclic antidepressants: amitriptyline, nortriptyline, dothiepin,
imipramine
 MAO Inhibitors
99
Agomelatine (Valdoxen)
 MT1/MT2 melatonergic agonist
 5-HT2C serotonergic antagonism
 Restores circadian rhythm and sleep-wake cycle
 Less sexual side effects
 Baseline LFT’s – repeat week 6,12 and 24
 Place in treatment still to be determined
100
Antidepressant Classes
Serotonergic
Noradrenergic
Dopaminergic
Selective
SSRIs

Dual Action
SNRIs


Mirtazapine






Broad Action
TCAs
MAOIs


What dose would you use?
SSRIs
 Start with a half dose and increase if tolerating side effects
 Effective dose varies with rate of metabolising
Tricyclic antidepressants
 Start 25mg titrate up to 150mg
(note: watch for QT prolongation)
102
What dose would you use?
Dual acting
 Venlafaxine start low and can increase to 225-300mg according
to response.
 Others start at one tablet –
– desvenlafaxine 50mg (up to 200mg) ,
– duloxetine 30mg
(up to 120mg)
– mirtazapine 30mg (up to 60mg).
103
Instructions
What do you need to tell Ellie when prescribing an
antidepressant?
(a) Side effects – which side effects would you warn her about?
104
Drug interactions and serotonin
syndrome
@
(b) Drug interactions and serotonin syndrome
Which medications can interact to cause serotonin syndrome?
 SSRIs, SNRIs,TCAs, MAOI
 Opioid analgesics: pethidine, tramadol, fentanyl,
dextromethorphan
 St John’s wort
 Amphetamines
 Methylenedioxymethamphetamine (MDMA; ecstasy)
105
Serotonin Syndrome
@
What are the symptoms of serotonin syndrome?
Neuromuscular
•Hyperreflexia
•Clonus
•Myoclonus
•Shivering
•Tremor
•Hypertonia/rigidity
Autonomic
•Hyperthermia:
mild, < 38.5°C;
severe ≥ 38.5°C
•Tachycardia
•Diaphoresis
•Flushing
•Mydriasis
Mental state
•Agitation
•Hypomania
•Anxiety
•Confusion
106
Time until it starts working
(c) How long will Ellie need to wait to get any positive benefit
from the medication?
 In melancholic depression it may take 2-3 weeks to respond to
medication
 In a non-melancholic depression a response may be seen earlier
107
Abrupt cessation of treatment
@
(d) What withdrawal symptoms can occur if an antidepressant is
ceased suddenly?
Discontinuation syndrome:
 flu-like symptoms, insomnia
 nausea
 imbalance, dizziness
 sensory disturbances,
 hyperarousal, insomnia
 vivid dreams, irritability
108
Discontinuation
Symptoms last one to two weeks
Which antidepressants are more likely to cause severe
discontinuation?
 Those with shorter half lives such as paroxetine, venlafaxine.
109
Length of treatment
(e) How long would Ellie need to stay on the medication?
– 6 months for first episode of non-melancholic depression
– 1 year for a first episode of melancholic depression.
– Longer for subsequent episodes.
110
Medication and alcohol
@
(f) What about alcohol?
 Alcohol can worsen depression
 Intoxication symptoms may occur more readily
 Increase in side effects experienced may occur
 Serious interaction with MAOIs
111
Changing medications
What do patients experience when changing from one
antidepressant to another?
What do we need to tell them?
– Give a clear written change over schedule
– Combination of discontinuation effects, early side effects of
the new medication and loss of antidepressant effect can be
very challenging
– Prepare extra support, reduced responsibility and frequent
contact through this period
See Changing Antidepressant medication fact sheet page 90
112
Feeling much better
 You prescribed an antidepressant for Ellie and within 4-5 days
she is feeling much better. She is energetic, alert and motivated.
She has some new ideas for managing the main desk differently
at work.
What do you make of this?
 How would you respond?
Ellie may be switching into a hypomanic state.
 Options are:
– stop the antidepressant and monitor her progress or
– continue the antidepressant at a low dose and observe her
closely
113
or… Not getting better
At 4 weeks, despite gradually increasing the dose, Ellie is still not
responding to the antidepressant you prescribed.
What would you do next?
 In a melancholic depression, augmentation with an atypical
antipsychotic may be helpful
 A low dose of olanzapine (2.5 -5 mg) or quetiapine (25-50mg)
for 2- 4 weeks can often accelerate improvement
 Prolonged treatment with these medications is best avoided
due to their side effect profile
 If she is still not responding it may be necessary to change the
antidepressant
 Aim of treatment is full remission of symptoms.
114
Jack - aged 57yrs
You have already been introduced to Jack in your
online predisposing activity
You will recall that Jack has a psychotic sub-type
of depression
What are they key features of psychotic depression?
•
•
•
•
Mood congruent delusions
Pathological guilt
Severe psychomotor changes
Pseudo-dementia
Psychotic depression is a psychiatric emergency
115
Treating psychotic depression
Treatment
ECT
Response
Rate
80%
Antidepressant and
antipsychotic
Antipsychotic alone
80%
Antidepressant alone
25%
Placebo
5%
33%
116
Medication Fact Sheets
See:
 Treatment for Unipolar Depression for information regarding
treatment approach to the various sub-types of depression
(pages 92-95)
 Antidepressant Regimes for more information regarding the
different antidepressants, their dose and side effect profile
(pages 88-89)
117
Priorities
We have looked at:
1.
Engagement
2.
Make a diagnosis including sub-type
3.
Exclude other illness (as appropriate)
4.
Assess risk
5.
Complete a formulation / Mental Health Treatment Plan
6.
Provide psycho-education
7.
Decide whether medication is indicated
After the break we will:
8.
Consider psychological therapies
9.
Foster support networks
10. Wellbeing planning/relapse prevention
118
(8) Psychological Strategies
 Psychological strategies are the main stay of treatment for
people with non-melancholic depression and may be a useful
adjunct to medication for patients with other sub-types of
depression as their cognitive ability improves
 Psychological strategies aim to both improve stress
management skills and reduce personality vulnerabilities
 Patients who have a completed mental health treatment plan
can currently access a Medicare rebate for 6 + 4 sessions of
focused psychological therapies in a calendar year
 ATAPS – 12 sessions for low income groups funded through
Medicare local
119
Internet based mental
health assistance
 There are also several options online to support management
of mild to moderate depression and anxiety
 e-Mental Health can fill the gap in services where face to face
therapy is not available or accessible and can also be used to
augment face to face therapy
 Training in the use of e-Mental Health Programs in primary care
is available for GPs through the Black Dog Institute eMHPrac
project
See information leaflet in your pack
120
www.mindhealthconnect.org.au
(resource portal)
121
On line psychological therapies
 On Track - www.ontrack.org.au
122
Mental Health On line
www.anxietyonline.org.au
123
Psychological strategies in Primary Care
 Several basic behavioural strategies are readily initiated in
primary care
 What are some of the behavioural techniques you employ
when treating patients with depression?
1. Sleep hygiene
2. Exercise prescription
3. Alcohol and substance reduction
4. Activity scheduling
5. Pleasant events
124
Psychological Strategies - Steve
Steve’s formulation:
 Predisposing: anxious-worrier personality, high expectations of
self as man/provider, flood and drought, financial stress,
 Precipitating: wife working in town
 Perpetuating: insomnia, social isolation, alcohol, beliefs about
help-seeking
 Protective: caring partner, children, wife in employment
125
Addressing personality vulnerabilities
 What psychological strategies could assist Steve to address his
anxious - worrier personality style?
 What would motivate Steve to undertake psychological
therapies?
126
Treating the anxious worrier
2 components of the anxious worrier experience:
 Anxiety – physical experience
 Worry – cognitive experience
2 common psychological approaches (next 3 slides) :
 Cognitive Behavioural Therapy
 Mindfulness-based therapy
127
Treating the Anxious worrier
CBT:
Anxiety?
 relaxation techniques (eg. PMR, breathing techniques) to
reduce hyperarousal
Worry?
 challenge unhelpful thoughts, reality testing, behavioural
experiments, graded exposure
128
Treating the Anxious worrier
@
Mindfulness based therapies
What is your understanding of the term ‘mindfulness’?
 In the present
 Non judgmental
 Awareness
“Consciously bringing awareness to the here and now
experience with openness, receptiveness and interest”.
(Dr Russ Harris)
 Experiential therapy that requires commitment to
practice
129
Mindfulness for the anxious worrier
 Anxiety - Accepting the physical sensations that
accompany anxiety without struggle, reducing the need
to avoid or get rid of these sensations
 Worry - Looking at worried thoughts and ruminations
without getting caught up in them, challenging them or
giving them attention
 Focusing on the present and living meaningfully rather
than living a life governed by anxious sensations and
worried thoughts
Mindfulness handouts in PTK (Section 3 of your workbook)
Dealing with Anxiety Disorders workshop
Stress management skills
 The psychological toolkit
contains many useful
worksheets to improve skills
to better manage stress.
 Learning structured problem
solving is particularly useful
for the anxious worrier.
 Let’s look at the problem
solving templates in the
toolkit
• Define the problem
• Generate solutions
• Consider Pros and cons
• Choose the best option
• Plan
• Review
131
Skills Practice
 Steve has identified that financial stress is a very significant
contributor to his distress.
 In your group of 3- clinician, Steve and observer, use the PTK
worksheets on problem solving pages 37 and 38 to work on this
issue.

You will need to first define the problem more specifically
before exploring possible solutions and working through these
 Allow Steve to generate his own solutions rather than
attempting to ‘fix’ the problem for him
132
Psychological Strategies - Steve
Steve’s formulation:
Predisposing: anxious-worrier personality, high expectations of
self as man/provider, flood and drought, financial stress,
Precipitating: wife working in town
Perpetuating: insomnia, social isolation, alcohol, beliefs about
help-seeking
Protective: caring partner, children, wife in employment
These can be listed in the issues/needs component of the MHTP
and form the basis for ongoing treatment planning (see next slide)
133
Steve’s Mental Health Treatment Plan
Jason (aged 38)
 Let’s listen to Jason who has been returned to have some
sutures removed from a laceration to his scalp sustained after a
fall one week ago
Meet Jason (play DVD )
(script is also in the workbook)
Note down any significant information in the history and your
observations of Jason in your workbook.
135
Jason
In small groups discuss:
 What are the key issues for Jason?
 What stressors are currently impacting on him?
 Can you see any “key and lock” effect in these stressors?
 What personality style does Jason have?
 What is the diagnosis for Jason ?
Discuss in large group
136
Social and Emotional Wellbeing
 Health and Welfare of Australia's Aboriginal and Torres Strait
Islander Peoples, Oct 2010
Social and Emotional Wellbeing:
• Most (70%) Aboriginal and Torres Strait Islander adults reported being happy
• Around one third of adults reported high/very high levels of psychological
distress
• Many Aboriginal and Torres Strait Islander people experienced discrimination
• Around one in twelve Aboriginal and Torres Strait Islander adults have
personally experienced removal from their natural family.
Aboriginal Mental Health
 Cultural awareness and sensitivity training is recommended for
health professionals working within Aboriginal communities
 This training is not within the scope of this program
 Recognition of the cultural and historic context of connection to
land, family and community together with multi- generational
trauma and loss is integral to managing Aboriginal social and
emotional wellbeing
 Where possible services that have been developed specifically
to meet the unique needs of Aboriginal people are preferred
but at times this may not be possible
Aboriginal Mental Health
 However, the skills of assessment, diagnosis, risk management
and developing a management plan that addresses the mental
health needs of the person are still required albeit modified to
acknowledge the unique culture and context in which the
episode has occurred
 Australian Indigenous Health Infonet provide excellent
resources in SEWB including fact sheet series
 Mental Health First Aid – Aboriginal and Torres Strait guidelines
 And key and lock
Irritable personality style
Questions in the TAPQ that look for irritable personality style
 I am very snappy when I’m stressed
 I can become quite grumpy and grouchy
 At times, I can get very cross with other people
 I have an excitable and quick temper
 I tend to be hot tempered
 I tend to get angry and lose my cool when stressed
 Under pressure I tend to get snappy
 Under pressure, I can get cranky with others and myself
140
Irritable personality style
@
When stressed, people with an irritable personality style:
 Outbursts of anger
 Snappy at other people
 Lash out at others
 Impatient with self
 Distracted by reckless/pleasurable pursuits eg drinking,
gambling
141
Jason - diagnosis
What is the diagnosis for Jason?
Management Planning
In small groups discuss:
 Would you prescribe medication(s) for Jason? Why
 Which medication(s) would you prescribe?
 Complete the formulation grid for Jason ( see next slide)
 Which of these can be addressed in the management plan?
 How would you collaborate with others in helping Jason?
 Complete the assessment component of the Mental Health
Treatment Plan
 Which psychological strategies would be helpful for Jason?
143
Formulation
 Predisposing: Mother from stolen generation, absent father
unemployment, eldest brother deceased, alcohol use, irritable
personality style
 Precipitating: Expecting second child, relationship stress
 Perpetuating: Frequent fights, increased alcohol use, insomnia
Which protective factors in the formulation can be drawn from
to assist in recovery?
 Connection with family and community, willing to assist others,
invested in wellbeing of partner and child
144
Jason
 Medication?
 Collaboration?
 What psychological strategies could assist Jason to address his
irritable personality style?
 Narrative therapy is recognised by Medicare as a form of FPS
useful for assisting ATSI people with psychological distress
145
Jason
 Frustration is a hybrid emotion composed of both anxiety and
anger
 We have discussed the use of CBT/ Mindfulness in managing
anxiety. These could also be beneficial for Jason
 Let’s focus now on anger management
 How would you motivate Jason to learn some anger
management skills?
146
Anger management
(1) First step is recognising the physical signs of anger in the body
and noticing these early:
 Think about a situation where you felt extremely angered
 Notice where in your body you feel the sensation of being angry
(2) When these sensations are extreme:
– STOP!
(can use visualisation – e.g. stop sign, flashing lights)
– BREATHE (reduce arousal through slow diaphragmatic
breathing)
– LEAVE
(or count to 10)
to defuse immediate situation…
147
Anger management
(3) Identify unhelpful cognitions -
What unhelpful thoughts would be fuelling Jason’s anger?
(4) Mindfulness and relaxation exercises can help reduce overall
arousal
148
Stress Management Skills
 What resources from the toolkit could help Jason better
manage stress?
149
Skills Practice:
Assertive Communication
 Jason needs to talk his cousin about some tools he borrowed
months ago that Jason now needs him to return so he can help
Jules’ father with some work on the family home. He would like
your help to communicate more effectively with his cousin.
 In your groups of 3, using the Honest Communication
worksheet, page 103-104 , help Jason prepare for this
conversation
»
Describe objectively
»
Express how you feel
»
Specify what you want
»
State Consequences
150
Priorities
1.
Engage
2.
Make a diagnosis including sub-type
3.
Exclude other illness (as appropriate)
4.
Assess risk
5.
Complete a formulation / Mental Health Treatment Plan
6.
Provide psycho-education
7.
Decide whether medication is indicated
8.
Consider psychological therapies
9.
Foster support networks
Fostering Support
7
What are the characteristics of good support?
 Non-judgmental
 Listening
 Assisting with appointments and referrals
 Encouraging to exercise, eat well and socialise
 Fostering hope
 Balancing encouraging autonomy with providing assistance
 Notice signs of relapse
152
Support
Where can support be found?
What are some of the supports available in your community?
Discuss
Support groups:
www.blackdoginstitute.org.au/public/gettinghelp/supportgroups.cfm
153
Relapse
Once the depression has remitted our focus can move helping our
patients stay well and reducing the risk of relapse
What factors can help our patients stay well and reduce the risk of
relapse?
These can be formalised in a written wellbeing plan which will
assist in maintaining wellness and decrease the likelihood of
relapse.
It can be useful to involve carers in some aspects of the wellbeing
plan.
154
Relapse
Despite our best efforts and the patient’s best efforts relapses still
occur.
 Helpful for patients identify their relapse signature
 Educate friends and family to recognise signs of relapse
 Be clear that you expect them to contact you when the early
warning signs occur so that their management plan can be
adjusted.
155
Summary
 Comprehensive management of clinical depression requires
working through the 10 steps delineated in the program today
 The management plan, however, will be unique for the
individual person depending on their bio-psycho-social-spiritual
context, depression sub-type and the risk issues in their
presentation
 Managing depression in rural areas can be more challenging
than in urban areas however there are strengths in rural
communities that can be mobilised to better assist people living
with depression
Thank you!
157