Depressive Illness and Antidepressants Guy Brookes Psychiatrist, Leeds MH Trust, CRHT

Content What is Depressive Illness Principles of Treatment Medication Options Medication Problems Other treatments

What is Depressive Illness Episode Recurrent problem Socially disabling Endogenous / Reactive

Key Symptoms Low Mood*, Hopeless Anhedonia – no pleasure* Lack of Energy Disturbed sleep / diet / sex drive Anxiety / Agitation / Retardation Difficulty thinking – “How are you managing at work” Reduced self worth / Guilt

What isn’t Depressive Illness Adjustment Disorder Dysthymia Personality Disorders Alcohol Problems Dementia

How Well do we Treat it Up to 50% not identified Up to 50% still depressed after 1 yr Detection not necessarily associated with better long term outcome

Mild depression Anti depressants not Indicated Education / Problem solving / Support / Exercise / Bibliotherapy Monitor (may develop!)

General Principles of Treatment Context – their life, home life Usual self Suicide / self harm risk Patient’s beliefs Common formulation

NICE Guidance For 18 yrs and over. Physical, social and psychological assessment Mild depression – “Watchful waiting” and defer antidepressants. First line treatment SSRI. – advise withdrawal synd. (and agitation on starting) If high suicide risk or under 30 yrs see after 1 week of starting. Otherwise 2 weeks.

Being NICE cont. If no response after 4 weeks switch.(partial response after 6 weeks) Venlafaxine – start and supervise by specialist services (to review) Cont antidepressant for at least 2 yrs if 2 or more episodes For severe depression consider antidepressant and CBT concurrently If relapsed despite antidepressant consider CBT Cessation – over at least 4 weeks Remember carers

When to use Antidepressants Mod / Severe Depressive Illness Patient Education – appropriate level Risk / Benefit Delay ?

How do Antidepressants Work? All increase availability of monoamine/s But delay! ? Abnormality in receptors ? Monoamine systems respond abnormally on a molecular level e.g.. BDNF

Principles of Prescribing Effective Dose Discuss Illness and Drug with patient Review soon after (1-2 weeks) Check Efficacy, Compliance, Side Effects and Suicide Risk Continue after Resolution

How to Choose an Antidepressant Previous Response, Patient views Efficacy Side Effects Safety Co-morbidity / associated symptoms Cost Contra indications / Cautions Familiarity

Efficacy c. 60% effective in short term 2 – 6 weeks Very little difference for first line Life events not important Compliance Dual action drugs

Effectiveness Single antidepressant – 50-65% respond Switch – 90% respond Relapse Cont antidepressant 10-25% Stop 50% Response not well

Side Effects Individual priorities Less troublesome if aware Linked with premature cessation Drug Interactions

The Candidates

Tricyclic Antidepressants Dose titration Fatal in Overdose Problematic side effects associated with poor compliance Physical illness Sedation, Anti-chol, CVS, Sexual dysfunction, Weight gain, Memory, Postural hypotension. (NB timing) Severe hospital Depression

SSRI’s Initial Agitation Withdrawal Effects Simple Doses Safer in OD Sertraline and Citalopram few interactions. Post MI and stroke, Epilepsy Nausea, Anxiety, racing thoughts, Sexual dysfunction, Headache. Serotonin synd. Co-morbid Anxiety / Obsessive symptoms

Are all SSRI’s the Same? Receptor affinity – benefits and problems Half lives – starting, stopping, switching Interactions Licence Tolerability / Safety

Reboxetine (NRI) No direct serotonin effect No sedation or sexual dysfunction Insomnia, agitation, postural hypotension. ?cognitive / motivation symptoms

Venlafaxine (SNRI) Dose titration Initial agitation Withdrawal effects Sexual dysfunction, Nausea / GI, Hypertension. Cardiotoxicity, fatality More effective at higher doses NB MHRA 31/5/06

Mirtazapine (NaSSA) Simple dose Weight gain and sedation Blood dyscrasias (?) Little sexual dysfunction May have increased efficacy

BAP Guidance In majority antidepressants equally efficacious. SSRIs more likely to be given at effective dose. Newer antidepressants better tolerated than TCAs. Initial weekly contact associated with improved compliance and short term outcome. Improved outcome by drug counselling but not leaflets alone. NB Placebo response!!! Continuation for 6 months halves relapse (same dose)

How do you Really Choose Safety Co morbidity Let Patient decide

And if it Doesn’t Work Check: Diagnosis Ongoing life events Compliance Adequate dose

Then: Increase Dose Switch Augment Psychotherapy

ECT NICE guidance Side effects Memory impairment short /long term monitor

If it Does Work Response, Remission, Recovery Single Episode cont for at least 6 months (halves relapse) Severe, Recurrent or Over 65 cont for 2yrs Cont with therapeutic dose Education regarding recurrence. Plan. Ensure full recovery 1/3-1/2 relapse in 12 months (most in first 4 months) Cessation – advise risk of discontinuation symptoms. Reduce gradually – c. 4 weeks

Non Drug Options CBT / Interpersonal Therapy / Problem Solving Therapy Mild / Mod rather than severe But not: Counselling St John’s Wort Self help

Secondary Care Complex formulation Bipolar Risks Treatment Resistance / stuck What do you want?

In BPAD Maximise mood stabiliser ?Lamotrigine Very cautious with antidepressants Non-drug options

Useful Sites www.bap.org.uk (consensus statements) www.nice.org.uk www.mhra.gov.uk www.rcpsych.ac.uk/mentalhealthinformation