Depression 2008

1. 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