S

Medication

management of anxiety

& depression

Dr Katie Simpson

GP Mental health lead East Berks CCG

NICE guidelines for Anxiety

Stepped Care

SSRIs and SNRIs in Anxiety

disorders

SSRI Licensed indication (in addition to

major depression)

Sertraline GAD, Panic, SAD, PTSD

Citalopram Panic

Fluoxetine OCD

Escitalopram GAD, Panic, SAD, OCD

Paroxetine GAD, Panic, SAD, OCD, PTSD

Venlafaxine GAD, Panic, SAD

Duloxetine GAD

Pregabalin in GAD

Benzodiazepines

S Do not offer BDZs for Rx of GAD apart from short-term

measures during a crisis.

S Avoid driving- even the next morning

S Can become habit forming after 2 weeks

S In long term can cause rebound insomnia and anxiety

Depression & suicide

S Early diagnosis of depression and prompt effective

treatment has a major role in preventing suicide across

the population

S 45% of those successfully completing suicide have seen their

GP in the previous month (77% in the previous year) vs 25%

under Secondary Care

S Affective disorders (32-47%) particularly depression

NICE depression threshold

prescribing

Network meta analysis of anti

depressant efficacy in major depression

Efficacy & tolerability of Anti-

depressants in major depression

Cipriani review: Does not

change current NICE guidance:

S In terms of efficacy, all antidepressants were more effective than placebo.

S Differences between antidepressants varied for efficacy and acceptability.

S In head-to-head studies amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine were more effective than other antidepressants.

S For acceptability, agomelatine, citalopram, escitalopram, fluoxetine, sertraline, and vortioxetine were more tolerable than other antidepressants

S Amitriptyline, clomipramine, duloxetine, reboxetine, trazodone, and venlafaxine had the highest dropout rates..

S 82% of the trials are considered to have a high or moderate risk of bias, with evidence classed as moderate to low certainty

S .Fluoxetine and paroxetine have a higher propensity for drug interactions.* For people who also have a chronic physical health problem, consider using citalopram or sertraline as these have a lower propensity for interactions.

S Paroxetine is associated with a higher incidence of discontinuation symptoms.

Antidepressants in pregnancy

S 3-10% of pregnant women

S Most (50-80%) women stop ADs when pregnant

S Relapse if AD stopped in pregnancy = 68% v. 26% (Cohen et al 2006) (>if several past episodes or recent)

SSRI: Absolute risk for any pregnant

women is LOW

S Are SSRIs associated with an increased risk of congenital malformations?

Conflicting data (- not controlled for obesity, drugs and alcohol, tobacco, psychiatric illness)

But SMALL ABSOLUTE RISK

S Are SSRIs associated with neonatal complications ?

- Probably, usually mild and self limiting

S Implications of stopping AD’s in pregnancy/ Prescribing sub therapeutically

- Potential increase in recurrence of depression and effect on mother and baby

S Avoid Paroxetine - but evidence not strong

S Sertraline appears to result in the least placental exposure

S Breast feeding < 10% into breast milk , lowest Sertraline

Early pharmacological approaches to

treatment resistant depression

Further Mx (NICE)

If person is informed and prepared to accept additional side

effects, consider augmenting with:

S Lithium

S An antipsychotic such as aripiprazole, olanzapine,

quetiapine, risperidone

S Another antidepressant, such as mirtazapine or venlafaxine

Network metanalysis of augmentation

treatments for resistant depression

Relapse prevention

Need to continue treatment for at least 6/12 from recovery

Continue medication for at least 2 years

(If 2+ recent episodes, other risk factors, relapse consequences severe e.g occupation)

Psychological interventions: For recurrent depression

Individual CBT (16-20 sessions over 3-4 months) OR

Mindfulness based cognitive therapy (8 week group)

NICE conclusions on antidepressant

medication

S When prescribing, should normally be SSRI in generic form

S Discuss all options

S Address patient concerns, views on tablets and antidepressants, and discuss common myths

Gradual effects and need to persevere

Side effects and drug interactions

Discontinuation symptoms

Not addictive

Ask about St. John’s Wort

S Review after 2 weeks, then at least monthly

S If suicide risk or <30years review after 1 week, then frequently

Ketamine

Ketamine: Rapid alleviation of

depression

Further experience with

Ketamine:

Summary

For anxiety Psychological treatment is preferred. SSRIs first line if treatment is needed

SSRI first line medication for depression. Mirtazepine is non- SSRI alternative

Switching within or between class is a reasonable option if pt with depression is insufficiently helped by an initial SSRI

Augmentation with low dose Mirtazepine/ Venlafaxine can be offered in Primary Care

Augmentation with low dose atypical antipsychotic is effective but adverse effect burden is troublesome.

Ketamine might provide symptomatic relief for pts who have persistent depressive symptoms despite multiple trials of psychological and drug treatment

Thank you

katiesimpson3@nhs.net