1. Depression & Antidepressants Fareed Bhatti Pennine VTS - November 2009

2. Format of Presentation Split into subgroups ….. ( if possible) 3 presenters About 15-20 minutes Covered Topics - New NICE guidelines for Depression(Oct 2009) - How to start, switching between antidepressants & stopping them. - Individual characteristics of Antidepressants - Antidepressants in Pregnancy Some AKT style questions (MCQs) thrown in somewhere….. Chocolates for right answers!

3. Why is it important? Worldwide lifetime incidence ~4-10% for major depression 2.5% and 5% for dysthymia ( chronic low grade symptoms) Numbers for UK ( King’s Fund report 2006): In 2006 1.24 million people with depression in England, By 2026 projected to rise by 17 % to 1.45 million. Costs:. In 2007 the total cost of services for depression in England ~ £1.7 billion with lost employment £7.5 billion. By 2026 cost ~ £3 billion & with lost employment £12.2 billion. QOF points (2009-2010) = 53 for depression -DM/CVD pts screened for depression in past 15 months - 8 points -New diagnosis in past year- formal assessment(e.g.PHQ9 ) - 25 points -Re-evaluate using the same tool in 5-12 weeks - 20 points

4. Question 1 What are the two screening questions for depression in primary care? (Chocolates only for telling both!)

5. Answer 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 having little interest or pleasure in doing things?

6. Question 2 Name any 7 symptoms that you would use to assess for depression?

7. Answer Symptoms of general low mood include: sadness and tearfullness low self-esteem guilt pessimism helplessness hopelessness apathy loss of interests anhedonia loss of concentration depersonalisation Paranoia Anxiety symptoms of depression include: tension apprehension phobic disorders The somatic features of depression include: loss of appetite weight loss constipation insomnia or hypersomnia amenorrhoea low libido psychomotor retardation or agitation Psychotic symptoms (severe depression): hallucinations typically derogatory auditory hallucinations delusions e.g. delusions of worthlessness

8. Severities of Depression Subthreshold: < 5 symptoms. Mild Depression : Just above 5 with minor functional impairment. Moderate: Symptoms or functional impairment between mild and severe. Severe: Most symptoms, marked functional impairment.

9. New NICE Guidelines for Depression-Salient points 1.Assessment Principles-duration and severity with degree of impairment should also be considered. 2.Encompasses adults with chronic illnesses as well. 3.Sub threshold depression recognised and guidelines given. 4.Diagnostic criteria has been changed from ICD-10 to DSM-IV so psychosocial therapies can be matched to the illness more appropriately. 5.Clearer role of psychosocial interventions defined but implications for existing overstretched services. 6.More accountability for the psychosocial interventions. 7.Guidance for relapse prevention-talking therapies+ meds.

10. Treatment of Depression with Chronic Illness - High Intensity psychosocial intervention - SSRI - Combination of both Low Intensity psychosocial intervention Collaborative care between primary and secondary care for long term Rx and follow up Treatment of Persistent sub-threshold(PST) Depressive symptoms

11. Important difference from previous guidance:. Not routinely but can consider antidepressant for -Subthreshold depressive symptoms with past history of moderate or severe depression. -Mild depression that complicates care of physical health problem -Initial presentation of PST > 2 years -PST or mild depression persisting after other interventions

12. Stepped Care Model. Assessment & Support; Education. Active monitoring & referral for further assessments & interventions All known & suspected presentations of depression. Low intensity psychological & psychosocial interventions. Medication. Referral for further assessments & interventions. Persistent sub- threshold depression &. Mild to Moderate. Medication. High intensity psychosocial interventions. Combined treatments. Collaborative care. Referral. PST / Mild to Moderate with inadequate response to initial interventions. Moderate and Severe. Medication. High intensity psychosocial interventions. ECT. Crisis service. Admission. Combined Treatments. Severe and Complex depression. Risk to life.Severe self neglect

13. Psychosocial interventions Low-intensity psychosocial interventions Indications: For PST depressive symptoms or mild to moderate depression +/- chronic physical health problem, PST symptoms that complicate care of the chronic physical health problem Preventing relapse Types ( guided by the patient’s preference) – Structured group physical activity programme – Group-based peer support (self-help) programme – Individual guided self-help based on the principles of CBT – Computerised CBT -- Group based mindfulness –based CBT High-intensity psychological interventions Indications Treatment for moderate depression For patients with initial presentation of moderate depression and a chronic physical health Preventing relapse of depression –some cases Types -- Group-based CBT / Interpersonal therapy/ behavioural activation – Individual CBT or -- Behavioural couples therapy for selected patients

14. Starting antidepressants The consultation: - Give choice - Explore I,C &Es - Discuss no addiction potential - Shouldn't discontinue suddenly - Need to continue beyond remission - Safety netting and follow up. Follow up - <30yrs or high risk of suicide- see after 1 week and then frequently. - Less risk of suicide- see after 2 weeks then 2-4 weeks uptil 3 months then longer intervals. Should the antidepressants ever be put on patient’s repeat medication?

15. Drug titration -If SEs early on monitor& reassure OR stop and change OR upto 2 weeks addition of benzodiazepine (according to symptoms and not for chronic anxiety). - 2-4 weeks Minimal response check compliance & increase support OR increase dose OR switch antidepressant Some improvement Continue for another 2-4 weeks & change antidepressant if inadequate response, SEs or patient choice.

16. Choosing and changing antidepressants Choosing: - Patient choice -SSRIs - Generic SSRI 1 st line- consider PPI in elderly or if on aspirin/ NSAIDs etc. - Sertraline /Citalopram for people with chronic illnesses as lower interactions. - Higher interactions with Fluoxetine, Fluvoxamine and Paroxetine. - Paroxetine – higher discontinuation symptoms. -TCAs - Higher toxicity risk in overdose except Lofepramine, so increase dose slowly. - Dosulepin(TCA) –not recommended because of high risk of toxicity with OD. -MAO Inhibitors/ Lithium or lithium augmentation-Psychiatrists Changing: SSRI Different SSRI or better tolerated newer generation drug Venlafaxine TCAs Another class

17. To:TCATrazodone SSRI (Citalopram, Sertraline, Paroxetine) SSRI (Fluoxetine) MirtazapineReboxetineMoclobemideVenlafaxine From TCA Cross-taper cautiously Halve dosage and add trazodone, then slow withdrawal Halve dosage and add SSRI, then slow withdrawal Halve dosage and add fluoxetine, then slow withdrawal Cross-taper cautiously Withdraw and wait at least 1 week Cross-taper cautiously starting with venlafaxine 37.5 mg/day Trazodone Cross-taper cautiously with very low dosage of TCA — Withdraw, then start SSRI Withdraw, then start fluoxetine Cross taper cautiously Withdraw, start reboxetine at 2 mg twice a day and increase cautiously Withdraw and wait at least 1 week Withdraw. Start at venlafaxine at 37.5 mg/day SSRI (Citalopram, Sertraline, Paroxetine) Cross-taper cautiously Withdraw, then start trazodone — Withdraw, then start fluoxetine Cross-taper cautiously Withdraw and wait at least 2 weeks Withdraw. Start venlafaxine 37.5 mg/day and increase very slowly SSRI (Fluoxetine) Stop fluoxetine. Start TCA at very low dosage and increase very slowly Stop fluoxetine. Wait 4–7 days, then start low- dose trazodone Stop fluoxetine. Wait 4–7 days, then start SSRI at low dose* and increase slowly — Withdraw and start mirtazapine cautiously Withdraw, start reboxetine at 2 mg twice a day and increase cautiously Withdraw and wait at least 5 weeks Withdraw. Wait 4-7 days. Start venlafaxine at 37.5 mg/day. Increase very slowly Mirtazapine Withdraw, then start TCA Withdraw, then start trazodone Withdraw, then start SSRI Withdraw, then start fluoxetine — Withdraw, then start reboxetine Withdraw and wait for 1 week Withdraw, then start venlafaxine Reboxetine Cross-taper cautiously — Withdraw and wait at least 1 week Cross-taper cautiously Moclobemide Withdraw and wait 24 hours — TCA, tricyclic antidepressant; SSRI, selective serotonin reuptake inhibitor. * Citalopram 10 mg/day; sertraline 25 mg/day; or paroxetine 10 mg/day.

18. Question 3 A 64 years old lady comes to see you 3 weeks after her husband’s death. You notice she looks depressed. She reports poor sleep, appetite, loss of pleasure in activities and feelings of depersonalisation. What would you suggest a)Sertraline. b)St John’s wort with light therapy. c)Bereavement counselling. d)Any combination of above.

19. Answer 3 Careful monitoring and Bereavement counselling. Although has a lot of features of depression and might very well develop into that, at present secondary to bereavement and therefore doesn’t qualify as true endogenous depression.

20. Stopping antidepressants & preventing relapse ▫Gradually reduce the dose over a 4 weeks, can be slower. Fluoxetine can usually be stopped over a shorter period(longer half life). ▫Some drugs like paroxetine and venlafaxine have a shorter half-life and more chances of discontinuation syndromes. (See GP notebook for table for reducing doses) ▫Discontinuation symptoms Management : - Mild = reassure and monitor. - Severe = reintroduction of original antidepressant at effective dose(or another antidepressant with a longer halflife) Started antidepressants Remission achieved Continue Meds for 6 more months same dose Significant risk of relapse OR Hx of Recurrent depression Significant risk of relapse OR Hx of Recurrent depression Continue meds for 2 years and then review Continue meds for 2 years and then review Thinking about stopping? - Is it recurrent illness - Any residual symptoms or - Continuing psychosocial /physical health problems Thinking about stopping? - Is it recurrent illness - Any residual symptoms or - Continuing psychosocial /physical health problems Augment meds if needed Psychological interventions- CBT or mindfulness based CBT

21. The End