Treatment for Depression

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Treatment for Depression

• Frederick Troncales, MD
• PGY 1 internal medicine
• Brown University/MHRI

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What are the Stats related to Depression?

• Lifetime risk of Major Depression is 7-12 in men
  and 20-25 in women
• 6.7 percent of the population, or about 14.8
  million American adults, will struggle with
  depressive illness
• 80 of depressed people are not currently having
  any treatment

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More Depression Stats

• 15 of depressed people will commit suicide
• Depression will be the second largest killer in
  2020 after heart disease- and it has been shown
  to be contributory to fatal heart disease ( WHO
  2001)
• Depression results in more absenteeism than
  almost any other physical d/o costing 51 Billion
  per year in lost productivity

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What is the pathophysiology of Depression?

• It has not clearly been defined
• Clinical and preclinical trials suggest
  disturbance in CNS serotonin activity.
• Other neurotransmitters implicated include NE and
  dopamine
• Clinical experience indicates a complex
  interaction between NT availability, receptor
  regulation and sensitivity and symptoms of MDD

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How do I diagnose Depression? DSM IV

• Depressed mood most of the day, particularly in
  the morning
• Markedly diminished interest or pleasure in
  almost all activities nearly every day
  (anhedonia) these can be indicated by the
  subjective account or observations by significant
  others
• Significant weight loss or gain
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Impaired concentration, indecisiveness
• Recurring thoughts of death or suicide

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• Symptoms should be present daily or for most of
  the day, or nearly daily for at least two weeks.
• Must cause clinically significant distress or
  impairment in functioning
• Not due to the direct effects of a substance (eg,
  drug abuse or medications) or a medical condition
  (eg, hypothyroidism)
• Do not occur within two months after the loss of
  a loved one
• A history of a prior manic episode in addition to
  these criteria suggests the diagnosis of bipolar
  disorder.

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How do I evaluate somebody with depression?

• Patients should have History, PE, and limited
  laboratory testing completed to rule out
  secondary medical causes
• Should be screened for Bipolar Disorder
• Assess for the presence of suicidal / homicidal
  ideation
• Assess if they have access to means of suicide

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• Presence of Psychotic symptoms, command
  hallucinations, severe anxiety
• Presence of alcohol and substance abuse

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PHQ - 9

• Allows measurement of diagnosis and severity of
  major depression
• Can monitor response to treatment
• To guide titration of antidepressant medication
  or response to psychotherapy

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What can I say to somebody whos depressed?

• Many patients are reluctant to accept a diagnosis
  of depression
• Maybe important to stress that Depression is
  common
• Frequently assoc. with fatigue, headache,
  abdominal pain
• It is a physical illness assoc with biologic
  changes in the brain including depletion of key
  chemicals called catecholamines

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• Treatment with either medication or psychotherapy
  generally shortens the course and diminishes
  symptoms such as fatigue, poor self esteem, etc..

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How can I improve my patients compliance to
Medications?

• Patients should be told
• Do not stop medications without talking to doctor
• There is LAG of 2-3 weeks before medications will
  relieve most symptoms
• S/E occur frequently during first few days but
  are gone after a week

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What are the different Antidepressants?

• Major Classes
• SSRI
• TCA
• Heterocyclics (Bupropion)
• MAO Inhibitor
• Meds that inhibit both NE and Serotonin reuptake
  Venlafaxine and Duloxetine

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• All available antidepressants appear to work via
  1 or more of the following mechanisms
• (1) presynaptic inhibition of uptake of 5-HT or
  NE
• (2) antagonist activity at presynaptic inhibitory
  5-HT or NE receptor sites, thereby enhancing
  neurotransmitter release
• (3) inhibition of monoamine oxidase, thereby
  reducing neurotransmitter breakdown.

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How effective are antidepressants?

• Studies concluded that antidepressants have a
  50-60 response rate in the primary care setting

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Which antidepressant should I use?

• Number of clinical studies and reviews have
  concluded that clinical outcomes, quality of life
  outcomes and overall treament costs provide no
  clear guidance on choice
• Most compelling reason SSRI are used as 1rst
  choice in primary care is lower severity of S/E
  and less danger with overdose

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What are the Side Effects?
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How do I start antidepressants?

• Starting at low doses can minimize the side
  effects of anitdepressants
• Paroxetine 5-10 mg / day
• Sertraline 12.5 to 25 mg / day
• Fluvoxamine 25 mg /day
• Escitalopram 10 mg / day
• Citalopram 20 mg / day
• Give for a week then gradually titrate up to full
  doses
• Usually taken in the morning
• For the first 8-12 hours can be stimulating and
  may disturb sleep

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How do I follow up?

• Patients need to check in every 2 weeks for 6-8
  weeks during initiation phase of medication
  treatment
• Initial therapeutic response typically occurs
  w/in 2 6 weeks
• More than half of eventual responders begin to
  respond by week 2
• Little evidence to support extending
  antidepressant therapy beyond 6 weeks in patients
  who have shown no response to maximal therapy

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What do I do if patient does not respond?

• If there is no response by 8 12 weeks at a
  maximum therapeutic dose
• Patient should be given a second trial of another
  antidepressant (same or different class)
• Patients antidepressant meds can be augmented
  with second drug such as Bupropion or Buspirone
• May refer to a psychiatrist

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What could possibly cause treatment resistance?

• Only 50 of patients in primary care respond to
  first choice of antidepressant
• 20 stop medication due to S/E
• 30 have no response
• Evaluate patient for chronic social stressors
  than can limit response to txt
• Panic d/o, PTSD, Marital discord, childhood
  adversity, alcohol/substance abuse
• Undiagnosed Bipolar d/o

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How long should I treat?

• Antidepressant medication taken at least 6-9
  months
• Inform patient that medication leads to a genuine
  change in underlying neurochemistry
• It takes weeks to adjust to being on/off
• Should be tapered off to minimize s/e

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Are Antidepressants safe in Pregnancy?

• As with other drug use during pregnancy, decision
  to treat depends upon balance of risks and
  benefits
• Placebo controlled trial done on Fluoxetine, TCA
  showed no difference in risks of developing major
  fetal malformations, low IQ scores, behavioral
  devt
• There maybe some adverse effect on fetus yet to
  allow a woman suffer from symptomatic depression
  during pregnancy can also result in unacceptable
  costs to mother and the fetus

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What do we do then?

• Mild to moderate depressed pregnant patients
• Should be treated with psychotherapy
• Severely depressed pregnant patients or those
  unresponsive to psychotherapy should receive
  pharmacotherapy
• SSRIs are pregnancy category C

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Do patients relapse?

• Relapse is relatively common once patients with
  major depression stop txt
• 2 major risk factors for relapse
• Persistence of subthreshold depressive sxs 7
  months after initiation of antidepressant txt
• History of 2 or more episodes of MD for 2 years

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What do we do with patients that relapse?

• Maintainance antidepressant txt can decrease rate
  of relapse
• AHPCR Guideline Panel recommended maintainance
  therapy for patients w/ a history of 3 or more
  depressive episodes and those with 2 depressive
  episodes plus risk factors that increase
  recurrence risk

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What is Electric Convulsive Therapy?

• Highly effective in pt w/ psychotic depression
• Effective for patient w/ severe melancholic
  depression on maximum medical therapy
• Meta-analysis of randomized trials concluded that
  ECT is an effective therapy for depression and is
  probably more effective than pharmacotherapy
• Decision for should be made with Psychiatrist
• Role of Primary care provider is to address
  patients fears and emphasize that the often
  quick response and low side-effect profile make
  it one of the most effective txt

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Elizabeth WurtzelAuthor

• It seemed like this was one big Prozac nation,
  one big mess of malaise. Perhaps the next time
  half a million people gather for a protest march
  on the White House greens, it will not be for
  abortion rights or gay liberation.
• but because were all so BUMMED out.

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THANK YOU