Depression/Treatment

From Ganfyd

Treatment

Psychological

Cognitive Behaviour Therapy (CBT) has been demonstrated to be an effective treatment for depression. However, it is not always available in primary care, it is relatively expensive (cost per course £100 -£160) and there may be a long waiting time. Refer via Community Mental Health Team as some CPN’s are specially trained in CBT. Alternatively refer to Consultant-led CBT Services if available, but waiting lists are 12-18 months. The patients have to be psychologically-minded and usually those with recurrent depression are more suitable as the course of their illness can be dramatically changed. Interpersonal psychotherapy may be offered in some Mental Health Trusts and has some proven efficacy with depressed patients. Both this psychological therapies appear to work best with patients of the YAVIS type ie Young, Attractive, Verbal, Intelligent, Solvent. There is no research evidence that Supportive Counselling or Brief psychodynamic therapy are of any benefit in terms of outcomes in depression.

CBT is a treatment that should be considered and may be offered to the patient, especially where there is concern about the side effects of drug treatment.

Referral of any depressed patient for specialist care by CPN/Psychiatrists/Hospital should be considered in the following circumstances:

High risk of suicide

Failure to respond to usual treatment (2 maybe 3 antidepressants)

Diagnosis difficult

Comorbid conditions in which the other illness or its treatment makes the treatment of depression problematic (for example serious physical illness or personality disorder)

Patients with psychotic depression who may require either combinations of different antidepressants or ECT.

Patients with bipolar disorder who represent a higher suicide risk during depressed phases and may need careful monitoring of lithium concentration.

Patients who become hypomanic/manic for the first time immediately after anti-depressant treatment (?Bipolar II)

Patients with little social support and who are the main carer for a sick relative or young children.

Associated complex Drug and/or Alcohol problems.

Following a serious attempt at suicide or repeated DSH when depressed.

Pharmacological

The SSRIs are the drugs of first choice for depression in patients with the following chronic conditions:

Cardiovascular disease Hepatic disease Renal disease Neurological disorders Diabetes (except Fluoxetine)

SSRI have recently been found to have an antiplatelet effect similar to Aspirin so caution is advised in patients with a history of GI bleeding. Use lowest effective dose or consider Mirtazapine, Trazodone or Reboxetine.

Selective Serotonin Reuptake Inhibitors (SSRIs):

SSRI Adverse effects: Nausea, diarrhoea, agitation, insomnia, dry mouth & blurred vision, hyponatraemia, sexual dysfunction (male & female), slighly lowers seizure threshold so caution in epilepsy. 10% of people stop taking them because of side effects.

Fluoxetine is safer in overdose than tri-cyclics. It is less sedative and has fewer side effects. It should be noted however, that SSRIs can provoke an initial increase in symptoms of anxiety for first few days. Symptoms of anxiety may be of relevance in this case and careful counselling of the patient with an explanation of the initial side effects and the lag time of action (2 weeks) is important in all cases.

Paroxetine – also for OCD, PTSD, Panic, Social phobia, try to avoid as sedation, orofacial dystonias and withdrawal effects common. Not to be used <18 years.

Sertraline – prevention of relapse, OCD, PTSD; contraindicated in Liver disease/failure, nausea less common.

Citalopram – panic, prevention of relapse; less nausea, few interactions hence better choice for elderly or polypharmacy.

Selective Serotonin & Noradrenaline Reuptake Inhibitors (SNRIs):

Use as second line following poor response to SSRIs. Should only be initiated in Secondary Care unless you have Special Interest Training such as GPwSI. Venlafaxine is good for Generalised Anxiety Disorder too. The therapeutic dose of Venlafaxine should be 75mg bd except in the elderly when 37.5 mg bd is reasonable. A reasonable starting dose is 37.mg bd for 3-7 days to aid tolerance of side effects, then rapidly increase after about 1 week to 75mg bd. After 2-4 weeks consider changing to Venlafaxine XL (Effexor XL) 150mg od at whatever time of day the paient prefers. If there is persisting depression, try 225mg od but consider referring to a Psychiatrist at this stage. Doses of 225mg or higher may raise BP, so monitor BP and consider another antidepressant in hypertensive patients.

Although Venlafaxine has a similar side effect profile to the SSRIs (Fluoxetine, Paroxetine), the cost is at least twice as much for a comparable course.

Duloxetine may be a practical alternative to venlafaxine, and since the initiation of the latter by GPs was discouraged in 2005 may become more commonly used.

Similar acting NASSAs which also increase serotonin and noradrenaline are worth considering in primary care. Mirtazapine (Zispin) is good for thin, agitated, anxious, poor sleepers as its side effect profile causes some weight gain, mild sedation and much less nausea and agitation compared to SSRI’s. Sexual dysfunction is very rare, if having to stop an SSRI.

Trazodone, related to TCAs – treats depression where sedation required, calming, safe, nausea but fewer anti-muscarinic and cardiovascular effects. Liquid available. Rarely priapism develops, discontinue immediately.

Monoamine oxidase inhibitors (MAOIs):

Phenelzine – leave for specialists, often 2nd/3rd line, as a rule do not start until 2 weeks after stopping ANY other anti-depressant, 5 weeks if Prozac; avoid tyramine-based foods and ephedrine based drugs/cough mixtures etc Moclobemide (Reversible inhibitor of Monoamine oxidase type A = RIMA), less potentiation of the pressor effect of tyramine.

Noradrenaline Reuptake Inhibitor (NARI):

Reboxetine – maintainence of improvement, improves social functioning, not really used much as insomnia, sweating, dry mouth, constipation and urinary hesitancy/retention happen too commonly.

Tricyclic antidepressants (TCAs):

Some e.g Clomipramine are more effective than SSRI’s. They are cheap and effective especially in severe depression, those patients with chronic pain or sleep problems. They are being used much less in the last 10 years as they are dangerous in overdose. 300 TCA deaths per year and people on them are 5 times more likely to be involved in Road Traffic Accidents. They should be avoided in cardiac illness and dementia. Because of their side effects 80% of people are given low doses which are then inadequate to treat depression effectively (and unsafe in overdose).

Try to avoid prescribing Dothiepin as this drug is dangerous in overdose, as with the other tri-cyclics, it can cause cardiac arrhythmia. If there is a high risk of self-harm, it would be preferable to use other drugs.

Non-response to antidepressant medication should not be assumed until 6-8 weeks of treatment have failed to produce a response. The patient must be encouraged to take medication daily, and not to miss doses. Explanation of the lag time (two weeks minimum) before treatment takes effect helps to avoid non-compliance. They must be encouraged to take medication regularly and not to miss doses. Changing anti-depressants should not be considered until there has been non-response over a period of 6-8 weeks.

All patients should continue for 6 months on an antidepressant after remission following acute treatment. Patients with more than two episodes of major depression should have maintenance treatment for at least 5 years.

Surgical