Depression Key slides

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Depression Key slides
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What is depression?

• NICE Full guideline CG90. October 2009

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• Wide range of mental health problems
  characterised by absence of a positive affect
  (lack of interest and anhedonia), low mood, and a
  range of associated emotional, cognitive,
  physical and behavioural symptoms
• What is normal?
• Major depressive illnesses identified by
  severity, persistence of other symptoms and the
  degree of functional and social impairment
• Consider duration, stage of illness and treatment
  history

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What are the burdens of depression?

• NICE Full guideline CG90. October 2009

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• Mental and physical suffering
• Social impairments
• Inability to communicate
• Disturbed relationships
• Changes in social functioning
• Martial relationships and neglect of children
• Stigma
• Reduced self esteem / confidence
• Reduced working ability
• Exacerbation of pain and distress associated with
  physical illness
• Economic burdens

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What causes depression?

• Shah PJ. Hosp Pharm 2002 9 219-22 Thompson C.
  Medicine 2000 28 1-5

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• Multifactorial and largely unknown
• Genetic predisposition
• 60 concurrence in twins
• Early childhood environment
• Lack of parental care or loss of mother?
• Social stress and life events
• Severe life events increase risk 6x in following
  6 months
• Neuroendocrine changes
• eg HPA axis
• Neurochemical changes
• No single pathway
• Other diseases
• Drugs

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What are some of the possible triggers for
depression?

• WHO 1998

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• Psychological
• Recent bereavement
• Relationship problems
• Unemployment
• Moving house
• Stress at work
• Financial problems
• Medications
• Antihypertensives
• H2 blockers
• Oral contraceptives
• Steroids

• Illness
• Infectious disease
• Chronic medical problems
• Alcohol abuse
• Substance abuse
• Other
• Family history
• Childbirth
• Menopause
• Seasonal changes

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How common is depression in the UK?

• NICE Full guideline 90
• CKS Depression Nov 2007. www.cks.nhs.uk

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• 5-10 consulting have major depression
• 130 per 1000 people
• 80 per 1000 (62) consult their GP
• 49 out of 80 (61) are subsequently not
  recognised
• 1 in 4 or 5 are referred to secondary care
• Dysthymia occurs in 1-4 of adults

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Identification and assessment NICE CG 90. Oct
2009

• Be alert to possible depression (particularly in
  those with a past history of depression or a
  chronic physical health problem with associated
  functional impairment) and consider asking people
  who may have depression
• During the last month, have you often been
  bothered by feeling down, depressed or hopeless?
• During the last month, have you often been
  bothered by little interest or pleasure in doing
  things?
• If yes to either follow-up (Whooley and
  Simon. New Engl J Med 2000343194250)

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Identification and assessment NICE CG 90. Oct
2009 NICE Full Guideline 90. Oct 2009

• Confirmation requires more detailed clinical
  assessment consider using a validated measure
  e.g. PHQ-9, HDRS, BDI
• Comprehensive assessment should not rely solely
  on symptom count. Consider
• Degree of impairment and/or disability
• Duration of episode
• Always ask a person with depression directly
  about suicidal ideas and intent.

PHQ Patient Health Questionnaire HDRS
Hamilton Depression Rating Scale BDI Beck
Depression Inventory
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Diagnosis of major depression by DSM-IVWilliams,
et al. JAMA 2002287116070 NICE CG 90. Oct
2009 Gruenberg AM, et al. 2005

• Depressed mood
• Loss of interest or pleasure (anhedonia)
• Insomnia or hypoinsomnia
• Appetite or weight change
• Fatigue or loss of energy
• Increased/decreased psychomotor activity
• Guilt or feelings of worthlessness
• Suicidal ideation

X
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Categories of severity from DSM-IVNICE CG 90.
October 2009

• Subthreshold
• lt 5 symptoms
• Mild
• Few if any symptoms in excess of the 5 required
  and resulting in only mild functional impairment
• Moderate
• Symptoms or functional impairment between mild
  and severe
• Severe
• Most symptoms and they significantly interfere
  with functioning

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Management of depressionThe stepped care
modelNICE CG 90. Quick Reference Guide Oct 2009
Antidepressants for duration of illness at
least 6 months
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NICE Step 2 persistent subthreshold depressive
symptoms or mild to moderate depression (1)NICE
CG 90. Oct 2009

• Consider offering low intensity psychosocial
  interventions
• Individual guided self-help based on cognitive
  behavioural therapy (CBT) principles
• Computerised cognitive behavioural therapy (CCBT)
• A structured physical activity programme
• Choice of intervention should be guided by the
  patients preference
• Group CBT may be offered for those who decline
  low-intensity treatments
• Offer advice on sleep hygiene, if needed
• Monitor
• those judged to recover without a formal
  intervention
• those with subthreshold depressive symptoms who
  request an intervention.

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Using antidepressants for persistent subthreshold
depressive symptoms or mild to moderate
depressionNICE CG 90. Oct 2009

• Antidepressants
• Not recommended for the routine treatment of
  persistent subthreshold depressive symptoms or
  mild depression because the risk-benefit ratio is
  poor
• Consider them for people with
• Past history of moderate or severe depression
• Initial presentation of subthreshold depression
  that has been present for a long period
  (typically gt2 years)
• Subthreshold depressive symptoms or mild
  depression that persists after other
  interventions.

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NICE Step 3 persistent subthreshold depressive
symptoms or mild to moderate depression with
initial inadequate response or moderate and
severe depression NICE CG 90. Oct 2009

• Options
• Antidepressant (normally SSRI), or
• High intensity psychological intervention
• CBT (group or mindfulness-based)
• Interpersonal Therapy (IPT)
• Behavioural activation
• Behavioural couples therapy, or
• A combination of antidepressants and
  high-intensity psychological intervention (CBT or
  interpersonal therapy) if moderate or severe
  depression
• Choice depends on patients preference, duration
  of episode, trajectory of symptoms, previous
  illness course and treatment response, likelihood
  of adherence to treatment, likely side effects.

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Which antidepressant?

• NICE CG 90. October 2009

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• SSRIs
• Equally effective as other antidepressants
• Have a favourable risk-benefit ratio
• Note
• Increased risk of GI bleeding
• Higher risk of drug interactions with fluoxetine,
  fluvoxamine and paroxetine
• Higher risk of discontinuation symptoms with
  paroxetine
• Consider toxicity in OD for those with
  significant suicide risk
• Venlafaxine associated with greater risk of death
  in OD
• TCAs (except lofeapramine) associated with
  greatest OD risk
• Discuss drug choice with patient
• Do not prescribe dosulepin

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Drugs other than SSRIsNICE CG 90. October 2009

• Need to consider..
• Likelihood of discontinuation due to side effects
  with venlafaxine, duloxetine and TCAs
• Cautions, contraindications and monitoring
  required
• Duloxetine and venlafaxine exacerbate
  hypertension
• Higher doses of venlafaxine may exacerbate
  arrhythmias and need to monitor BP
• TCAs may cause postural hypotension / arrhythmias
• Mianserin needs haematological monitoring in
  elderly
• Non-revesible MAOIs eg phenelzine normally only
  prescribed in secondary care
• Do not prescribe dosulepin

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What should you discuss with the patient?

• NICE CG 90. October 2009

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• Explore their concerns and give a full
  explanation including
• Gradual delay in onset of full effect
• Take as prescribed and continue for 6 months
  after remission
• Information on potential side effects
• Potential for interaction with other medicines
• The risk and nature of discontinuation symptoms
  (especially if drug has a shorter half-life eg
  paroxetine and venlafaxine
• Addiction does not occur

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• During the initial treatment stages there is a
  potential for
• Agitation
• Anxiety
• Suicidal ideation
• Be vigilant of mood changes, negativity or
  hopelessness especially during high-risk periods
• When the illness is severe or persistent
  information and support should be offered to the
  carer

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What about St Johns wort?
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• May be of benefit in mild to moderate depression,
  but do not prescribe because of
• Uncertainty about appropriate dose and
  persistence of effect
• Variation in the nature of the preparation
• Potential serious interactions with other drugs
  (eg OCP, anticoagulants and anticonvulsants)
• Inform patients of these issues and the different
  potencies available

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How should you follow up patients?

• NICE CG 90. October 2009

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• If no increased risk of suicide
• See after 2 weeks
• Then regularly (eg every 2-4 weeks for 1st 3
  months)
• Longer intervals thereafter if good response
• If lt30 years or increased risk of suicide
• See after 1 week
• See frequently until risk not considered
  significant

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• If no improvements after 2-4 weeks on 1st drug
  check adherence
• After 3-4 weeks if response is absent / minimal
  consider
• Increasing dose
• Switching antidepressant
• If some improvement by 4 weeks, continue for
  another 2-4 weeks
• If response inadequate consider switching drugs

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How long should you continue medication?

• NICE CG 90. October 2009

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• At least 6 months after remission
• Explain
• This greatly reduces the risk of relapse
• Antidepressants arent associated with addiction
• Review with patient need to continue longer than
  6 months. Consider
• Number of previous episodes
• Presence of residual symptoms
• Other health problems
• Psychosocial difficulties
• For patients at risk of relapse, continue for at
  least 2 years

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How should you stop or reduce dose of
antidepressants?

• NICE CG 90. October 2009

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• Slowly over a 4 week period (some may need
  longer)
• Due to long half-life no need with fluoxetine

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What should you do if patients do not respond to
initial treatment?

• NICE CG 90. October 2009

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• Check adherence and any side effects
• Increase frequency or appointments and
  assessments
• Options
• Reintroduce previous treatments that have been
  inadequately delivered or adhered to
• Increase the dose
• Switch to an alternative antidepressant
• Combine drugs (consult with a psychiatrist)

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Switching drugsNICE CG 90. October 2009

• The evidence for the relative advantage of
  switching either within class or between classes
  is weak
• Reasonable choices for 2nd antidepressant
• Initially a different SSRI or better tolerated
  newer generation SSRI
• Subsequently switching to an antidepressants that
  may be less well tolerated eg venlafaxine, a TCA
  or an MAOI
• Caution with switching
• From fluoxetine to other antidepressants
• From fluoxetine or paroxetine to a TCA
• To a new serotonergic antidepressant or MAOI
• From a non-reversible MAOI

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Combining drugsNICE CG 90. October 2009

• Only start in primary care in consultation with a
  psychiatrist
• Consider adding
• Lithium
• An antipsychotic (eg aripiprazole, olanzapine,
  quetiapine or risperidone none licensed for
  depression in the UK
• Another antidepressant (eg mianserin or
  mirtazapine in augmenting)

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Augmentation treatmentNICE CG 90. October 2009

• Not recommended routinely
• Antidepressant benzodiazepine gt2 weeks
• Risk of dependence
• Antidepressant busiprone / carbamazepine /
  lamotrigine / valproate / pinodol / thyroid
  hormones (none licensed in UK for depression)
• Insufficient evidence

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How might you ensure safety in prescribing?

• NICE CG 90. October 2009

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• Monitor symptoms and side effects eg anxiety,
  agitation, mood changes and suicide risk
  (especially if lt30 years), particularly when
  initiating treatment and warn of possibility
• If high suicide risk
• Limit prescription quantity
• Consider additional support (primary care staff
  or telephone contact)
• Monitor for relapse and discontinuation /
  withdrawal symptoms when reducing or stopping
  medication
• If not at risk of suicide see after 2 weeks,
  thereafter every 2-4 weeks in the 1st 3 months

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• Continue for at least 6 months after remission
• Consider interactions with other drugs
• Consider specific cautions, contraindications and
  monitoring requirements
• Non-reversible MAOI normal prescribed by
  specialist
• Dosulepin not recommended
• Do not initiate 2 drugs together in primary care
  unless advised by a consultant

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When should you refer?

• NICE CG 90. October 2009

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• Severe depression
• Moderate depression and complex disorders
• Significant risk of self-harm
• Psychotic symptoms
• Those requiring complex multiprofessional care
• When depression fails to respond to various
  strategies for augmentation and combination
  treatments
• Where an expert opinion on treatment and
  management required

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Which non-drug treatments are recommended?

• NICE CG 90. October 2009

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Low intensity psychosocial interventions

• Individual guided self-help based on cognitive
  behavioural therapy (CBT) principles
• Computerised cognitive behavioural therapy (CCBT)
  Beating the Blues www.beatingtheblues.co.uk and
  MoodGYM www.moodgym.anu.edu.au
• A structured physical activity programme

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High intensity psychological interventions

• CBT (group or mindfulness-based)
• Interpersonal Therapy (IPT)
• Behavioural activation
• Behavioural couples therapy

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Others

• Counselling
• Short-term psychodynamic psychotherapy
• Group-based peer support programmes is a
  low-intensity option for those with chronic
  physical health problems

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Case study 1
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• Working through this case study will help you to
• Review your practice relating to the
  identification and assessment of people with
  possible depression
• Prioritise treatment for people who present with
  mild depression
• Advise patients who start treatment with an
  antidepressant

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• Mrs C is a 53-year-old woman presenting with
  symptoms of irritability, low mood and feeling
  that she cannot cope. She has been experiencing
  these symptoms for the past month, but has been
  reluctant to bother you about them
• She has been experiencing family problems with
  her husband and children for the last several
  months. She has asthma, but she denies that this
  is problematic at the moment. She has previously
  smoked 20 cigarettes per day and managed to stop
  six months ago. Now she feels so low that she has
  started smoking again, although she says she
  can't really afford to

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• She accepts that she hasn't been getting out of
  the house much recently when her family have
  asked her to go out with them, but adds that she
  is less active during the winter months anyway
  she often prefers to stay in and watch
  television. Her husband has commented that she is
  drinking more alcohol than normal
• A friend had recommended that she takes St John's
  wort for her mood and she has been for the last
  few weeks. She says that she hasn't noticed any
  significant change, but feels more anxious about
  her life and wants to know what can be done to
  help

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List the possible triggers for Mrs C's symptoms
of depression?
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• Recent bereavement
• Relationship problems
• Unemployment
• Moving house
• Stress at work
• Financial problems
• Family history of depression
• Menopause
• Seasonal changes
• Over use of alcohol and / or corticosteroids

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• At her last appointment, which was over one year
  ago for treatment of her asthma, it was noted
  that Mrs C had not been using her inhalers in the
  correct manner and the clinical records show that
  the she was less communicative than normal
• What two questions could have been asked at the
  time to help identify depression?

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What two questions could have been asked at the
time to help identify depression?
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• During the last month, have you often been
  bothered by feeling down, depressed or hopeless?
• During the last month, have you often been
  bothered by little interest or pleasure in doing
  things?

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• If Mrs C answers "yes" to either question, she
  may be depressed and further assessment is needed
• Adding in the question "Is this something with
  which you would like help?" to the two screening
  questions for depression, improves the
  specificity of the two question approach in
  general practice, i.e. it helps to rule IN the
  diagnosis of depression and is less likely to
  give a false positive result
• If Mrs C answers "no" to both questions, this
  does not necessarily always exclude depression
  further assessment is necessary if depression is
  still suspected

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• Mrs C answers "yes" to both of these two questions

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What further three questions do NICE recommend
asking to improve the accuracy of the assessment
of depression in people who have chronic physical
health problems
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• During the last month, have you often been
  bothered by feelings of worthlessness?
• During the last month, have you often been
  bothered by poor concentration?
• During the last month, have you often been
  bothered by thoughts of death?

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How should Mrs C be assessed further?
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• Assessment should not rely simply on a symptom
  count, but it should take into account both the
  degree of functional impairment and/or disability
  associated with the possible depression and the
  duration of the episode
• The Patient Health Questionnaire, the Hamilton
  Depression Rating Score or the Beck Depression
  Inventory should be considered
• NICE recommends that patients with depression are
  always asked directly about suicidal ideas and
  intent, and that help is arranged that is
  appropriate to their level of risk
• The updated 2009 NICE guidelines (CG90 and CG91)
  decided to adopt DSM-IV for diagnosis of
  depression in adults rather than ICD-10, which
  was used in the previous guideline

64

• Using a validated measure of severity, Mrs C
  appears to have mild depression. She hasn't
  previously been diagnosed with depression

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What treatment options you would recommend?
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• People with mild depression should usually be
  offered one or more low-intensity psychosocial
  interventions initially
• These include
• Individual guided self-help based on the
  principles of cognitive behavioural therapy (CBT)
• Computerised CBT (CCBT)
• Structured physical activity programme
• The effectiveness of counselling in managing
  depression is uncertain and so it is now only
  recommended as an option for Mrs C, if she
  declines other more established treatments
• Antidepressants aren't recommended for the
  routine treatment of mild depression because the
  risk-benefit ratio is poor. However, they may be
  considered where mild depression persists after
  other interventions

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• Although there is evidence that St John's wort
  may be of benefit in mild or moderate depression
• NICE recommends that practitioners should not
  prescribe or advise its use by people with
  depression
• There is uncertainty about the appropriate dose
  and persistence of effect, variation in the
  nature of the preparations available and
  potential serious interactions with other drugs
  (including oral contraceptives, anticoagulants
  and anticonvulsants)

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What would you do if Mrs C refused any
psychosocial treatment for her depression?
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• NICE recommends that people with mild depression
  who do not want an intervention should be
  assessed again, normally within two weeks
• If they do not attend follow-up appointments,
  contact should be made with them
• In addition, Mrs C should be given information
  about the nature and course of her depression and
  the presenting problems, and any concerns she may
  have about them should be discussed. This is also
  recommended for patients who are judged by the
  practitioner to recover without a formal
  intervention

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Mrs C mentions that she has had difficulty
sleeping recently. How would you advise her?
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• Practical advice on sleep hygiene for Mrs C could
  include
• Establishing regular sleep and wake times
• Creating a proper environment for sleep
• Taking part in regular physical activity
• In addition she has been drinking more alcohol
  than normal and has started smoking again
• She should be advised to avoid drinking alcohol
  and smoking (along with excess eating, if
  relevant) before sleep
• It would be helpful to reassure Mrs MC that
  insomnia is a common symptom of depression, and
  this might improve with treatment

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• Mrs MC chooses to try computerised CBT and
  regular physical activity
• You follow her up regularly, but her depression
  symptoms have not improved and after 6 weeks she
  returns to you asking if she can try an
  antidepressant?

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What other options could you offer her at this
stage?
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• NICE recommends that patients with mild
  depression and an inadequate response to initial
  treatments may be offered either an
  antidepressant or a high-intensity psychological
  therapy
• High-intensity psychological therapies include
• CBT
• Interpersonal therapy (IPT)
• Behavioural activation
• Behavioural couples therapy

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After explaining, and offering, a high-intensity
non-drug option to Mrs MC, she decides that she
would still prefer to try an antidepressant. What
factors should influence the choice of drug?
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• Antidepressants have largely equal efficacy and
  so the choice of drug should be largely dependent
  on
• Side-effect profile
• Patient preference
• Previous experience of treatments
• Propensity to cause discontinuation symptoms
• Safety in overdose
• Interaction potential
• Normally an SSRI in generic form should be chosen
  as SSRIs have a favourable risk-benefit ratio

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When prescribing an antidepressant, what advice
would you give to the patient to help with
concordance?
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• Good practice would be to explore any concerns
  the patient may have about taking medication and
  give a full explanation of the reasons for
  prescribing. Information to provide about taking
  antidepressants includes
• The gradual delay in obtaining the full
  antidepressant effect
• The importance of taking medication as prescribed
  and the need to continue treatment for at least 6
  months after remission
• Information on potential side effects
• Potential for interactions with other medicines
• The risk and nature of discontinuation reactions
  (e.g. with shorter half-life drugs such as
  paroxetine and venlafaxine) and how to minimise
  them
• Addiction doesn't occur with antidepressants
• It is also worth advising the patient of the
  potential for increased agitation, anxiety and
  suicidal ideation in the initial phases of
  treatment