Dr Maryam Naeem GPST2 Psychiatry Depression Dr Maryam Naeem GPST2 Psychiatry

Depression RCGP Learning outcomes Diagnostic criteria NICE guidelines AKT questions

RCGP Curriculum statement 13: Care of people with mental health problems Risk factors for mental health problems, the difference between depression and emotional distress Diagnostic criteria for people experiencing mental health problems How to screen for mental illness, using effective and reliable instruments

RCGP Learning outcomes Specific interventions and guidelines for individual mental health conditions (SIGN/NICE) Principles of mental health promotion Sufficient knowledge of the Mental Health Act

Depression in primary care Prevalence 5-10% in primary care Ranks 4th as cause of disability worldwide Suicide 2nd leading cause of death in persons aged 20-35 years 2/3 of patients meet criteria for another psychiatric disorder (anxiety, substance misuse, alcohol dependency, PD)

Symptoms needed to meet criteria for ‘depressive episode’ ICD-10 Group A symptoms Depressed mood Loss of interest and enjoyment Reduced energy and decreased activity

Diagnostic criteria ICD-10 Group B symptoms Reduced concentration Reduced self-esteem and confidence Ideas of guilt and unworthiness Pessimistic thoughts Ideas of self-harm Disturbed sleep Diminished appetite

Diagnostic criteria ICD-10 Mild: At least 2 of A + 2 of B Moderate: At least 2 of A + 3 of B Severe: All 3 of A + at least 4 of B The severity of symptoms and degree of functional impairment also guide classification

Biological symptoms Loss of emotional reactivity Diurnal mood variation Anhedonia EMW Psychomotor agitation or retardation Loss of appetite and weight Loss of libido

Other subtypes depressive disorder Atypical depression Agitated depression Postnatal depression SAD Premenstrual dysphoric disorder

Depression screening tools PHQ-9 HADS Becks inventory EDPS GDS

NICE Guidelines Key priorities for implementation Screening in primary care and general hospital settings 2) Watchful waiting 3) Antidepressants in mild depression 4) Guided self help 5) Short term psychological treatment

NICE Key priorities 6) Prescription of an SSRI 7) Tolerance and craving, and discontinuation/withdrawal symptoms 8)Initial presentation of severe depression 9)Maintenance treatment with antidepressants 10)Combined treatment for treatment resistant depression 11) CBT for recurrent depression

Treatment of mild depression Watchful waiting Sleep & anxiety management Exercise Guided self-help Computerised CBT

Treatment of mild depression- Psychological interventions Consider psychological treatment specifically focused on depression Problem solving therapy Brief CBT Counselling 6-8 sessions over 10-12/52 Where significant co-morbidity exists , consider extending treatment duration

Drug treatment mild depression ‘Antidepressants are not recommended for the initial treatment of mild depression, because the risk-benefit ratio is so poor’ Persistent symptoms – SSRI Mild depressive episode in those with a hx of moderate or severe depression - SSRI

Treatment of moderate to severe depression ‘In moderate depression, offer antidepressant medication routinely, before psychological interventions’ Delay in onset of effect Risk assessment – See those considered high risk of suicide and <30 1/52 post initiation, limit quantity prescribed

Treatment of moderate to severe depression - SSRIs 5HT1A agonism Antidepressant, anxiolytic, amti-obsessive and anti-bulimic effects 5HT2 agonism Agitation, akithisia, anxiety/panic, insomnia, sexual dysfunction 5HT3 agonism Nausea, GI upset, diarrhoea, headache

Treatment of moderate to severe depression - SSRIs As effective as TCAs and less likely to be discontinued beacuse of SEs Generic – Fluoxetine or citalopram Consider toxicity in overdose in patients at significant risk of suicide Highest risk TCAs (except lofepramine) Venlafaxine more dangerous than other equally effective drugs

Treatment of moderate to severe depression If increased agitation develops early in treatment with an SSRI, provide appropriate information and, if the patient prefers, either change to a different antidepressant or consider a brief period of concomitant treatment with a benzodiazepine followed by a clinical review within 2 weeks.

St Johns wort May be of benefit in mild to moderate depression Should not be prescribed or advised – uncertainty OTC potencies and liver enzyme inducer

Failure of 1st line treatment Consider switching to another anti-depressant if no response after 4/52 If partial response, a decision to switch can be postponed until 6/52 Treatments such as dosulepin, phenelzine, combined antidepressants, and lithium augmentation of antidepressants should be routinely initiated only by specialist mental healthcare professionals (including General Practitioners with a Special Interest in Mental Health)

2nd line treatment Choice for a 2nd antidepressant include a different SSRI or Mirtazapine Alternatives include: Moclobemide Reboxetine Lofepramine Consider other TCAs (except dothiepin) and venlafaxine, especially for more severe depression

Stopping or reducing drugs Reduce doses gradually over a 4/52 period Warn about possible reactions: SSRIs – headache, nausea, paraesthesia, dizziness and anxiety Withdrawal of other antidepressants (esp MAOIs) - nausea, vomiting, headache, ‘chills’, insomnia, restlessness

Special considerations: Venlafaxine Increased likelihood of patients stopping treatment because of SEs Uncontrolled hypertension 300mg or more only under supervision or advice of psychiatrist Measure BP at initiation and during treatment Cardiac dysfunction

Special patient characteristics Women – poorer toleration of imipramine Sertraline 1st choice in those with recent MI or unstable angina ECG and BP must be checked before starting a TCA in a patient at significant risk of CVD Venlafaxine and TCA contraindicated in those with recent MI or high risk serious cardiac arrhythmias

Summary Mild: Non-pharmacological Moderate-severe: SSRIs, different SSRI or Mirtazapine, Moclobemide, Reboxetine or Lofepramine Assess risk - Always ask directly about suicidal ideation

AKT Questions Which of the following is the most appropriate first line management for mild depression? A) Citalopram B) CBT C) Fluoxetine D) Paroxetine E) Psychodynamic psychotherapy

AKT Question 2 Which one of the following is a risk factor for the development of depression? A) Antisocial personality traits B) Anxious/avoidant personality traits C) High incidence of expressed emotion D) Male sex E) Paranoid personality traits

AKT Question 3: Side effects of antidepressants A) Amitriptyline B) Citalopram C) Fluoxetine D) Lamotrigine E) Mirtazepine F) St Johns wort G) Tryptophan H) Venlafaxine

AKT Question 3 1) Sedation and weight gain are common side effects 2) This antidepressant can cause a rise in anxiety levels during initial titration 3) BP should be monitored during initiation of this antidepressant 4)EPSE can occur with this antidepressant 5)Caution should be exercised when choosing an antidepressant in a patient who is self-medicating with this

Final Question...

Thank you

References 1)Semple et al, Oxford Handbook Clinical Psychiatry, OUP 2005 2)NICE Summary PDF Depression 2007 3)Gelder et al, Shorter Oxford Textbook of Psychiatry, OUP 2008