Depressive Illnessand

Antidepressants

Guy Brookes

Psychiatrist, Leeds MH Trust, CRHT

Content

• What is Depressive Illness

• Principles of Treatment

• Medication Options

• Medication Problems

• Other treatments

What is Depressive Illness

• Episode

• Recurrent problem

• Socially disabling

• Endogenous / Reactive

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

What isn’t Depressive Illness

• Adjustment Disorder

• Dysthymia

• Personality Disorders

• Alcohol Problems

• Dementia

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

Mild depression

• Anti depressants not Indicated

• Education / Problem solving / Support / Exercise / Bibliotherapy

• Monitor (may develop!)

General Principles of Treatment

• Context – their life, home life

• Usual self

• Suicide / self harm risk

• Patient’s beliefs

• Common formulation

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.

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

When to use Antidepressants

• Mod / Severe Depressive Illness

• Patient Education – appropriate level

• Risk / Benefit

• Delay ?

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

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

How to Choose an Antidepressant

• Previous Response, Patient views• Efficacy• Side Effects• Safety• Co-morbidity / associated symptoms• Cost• Contra indications / Cautions• Familiarity

Efficacy

• c. 60% effective in short term

• 2 – 6 weeks

• Very little difference for first line

• Life events not important

• Compliance

• Dual action drugs

Effectiveness

• Single antidepressant – 50-65% respond

• Switch – 90% respond

• Relapse

Cont antidepressant 10-25%

Stop 50%

• Response not well

Side Effects

• Individual priorities

• Less troublesome if aware

• Linked with premature cessation

• Drug Interactions

The Candidates

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

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

Are all SSRI’s the Same?

• Receptor affinity – benefits and problems

• Half lives – starting, stopping, switching

• Interactions

• Licence

• Tolerability / Safety

Reboxetine(NRI)

• No direct serotonin effect

• No sedation or sexual dysfunction

• Insomnia, agitation, postural hypotension.

• ?cognitive / motivation symptoms

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

Mirtazapine(NaSSA)

• Simple dose

• Weight gain and sedation

• Blood dyscrasias (?)

• Little sexual dysfunction

• May have increased efficacy

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)

How do you Really Choose

• Safety

• Co morbidity

• Let Patient decide

And if it Doesn’t Work

• Check: Diagnosis

Ongoing life events

Compliance

Adequate dose

• Then: Increase Dose

Switch

Augment

Psychotherapy

ECT

• NICE guidance

• Side effects

• Memory impairment

short /long term

monitor

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

Non Drug Options

• CBT / Interpersonal Therapy / Problem Solving Therapy

Mild / Mod rather than severe

• But not: Counselling

St John’s Wort

Self help

Secondary Care

• Complex formulation

• Bipolar

• Risks

• Treatment Resistance / stuck

• What do you want?

In BPAD

• Maximise mood stabiliser

• ?Lamotrigine

• Very cautious with antidepressants

• Non-drug options

Useful Sites

• www.bap.org.uk (consensus statements)• www.nice.org.uk• www.mhra.gov.uk• www.rcpsych.ac.uk/mentalhealthinformation