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

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

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

4. 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

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

6. 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

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

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

9. 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.

10. 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

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

12. 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

13. 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

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

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

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

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

18. The Candidates

19. 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

20. 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

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

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

23. 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

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

25. 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)

26. How do you Really Choose
Safety
Co morbidity
Let Patient decide

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

28. Then: Increase Dose
Switch
Augment
Psychotherapy

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

30. 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

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

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

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

34. Useful Sites www.bap.org.uk (consensus statements) www.nice.org.uk