1. A common GP consultation 10% of our pts, 80% managed in primary care
Depression 2008
A common GP consultation
10% of our pts,
80% managed in primary care

2. 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

3. 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

4. Somatic Symptoms Loss of appetite Weight loss Insomnia/Hypersomnia
Amenorrhea
Low libido
Psychomotor retardation/agitation
Constipation

5. 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’

6. 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

7. 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)

8. 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.

9. 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

10. 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

11. 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.

12. Common drugs tricyclic antidepressants
serotonin-selective reuptake inhibitors
noradrenergic and and specific serotonergic antidepressants

13. 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

14. 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

15. 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)

16. 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

17. 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

18. 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

19. 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

20. 2nd line agents
Mirtazepine – good for sedation (often w gain) alpha-adrenoceptor 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