1. Dr Maryam Naeem GPST2 Psychiatry
Depression
Dr Maryam Naeem
GPST2 Psychiatry

2. Depression RCGP Learning outcomes Diagnostic criteria NICE guidelines
AKT questions

3. 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

4. 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

5. 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 years
2/3 of patients meet criteria for another psychiatric disorder (anxiety, substance misuse, alcohol dependency, PD)

6. 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

7. 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

8. 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

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

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

11. Depression screening tools
PHQ-9
HADS
Becks inventory
EDPS
GDS

12. 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

13. 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

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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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.

21. 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

22. 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)

23. 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

24. 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

25. 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

26. 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

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

28. 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

29. 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

30. 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

31. 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

32. Final Question...

33. Thank you

34. 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