Effective care for depression requires
Psychosocial support & Education – Prodigy leaflets
Self Help - Mood Gym
Reading List- (To be added)
Self Help -Mood Gym
- Reading List- (To be added)
Referral to Mental Health Specialists
Drug Therapy- Which drug to use
Antidepressants in Pregnancy and Breast-feeding
Benefits of screening
Enhanced Service standards require the use of screening procedures and note that recognition of depression improves outcome even when the patient does not comply with treatment.
Early detection and treatment of depression seems to decrease the duration of the illness.
Direct presentation of depression is d
As many as 40-60% of depressed people volunteer physical symptoms to their GP, rather than psychological symptoms. This may be because they do not recognise their symptoms as psychological or because of fears about stigma. Screening instruments make it easier for them to discuss their experiences and concerns.
Studies show a marked variation in the ability of general practitioners to make the diagnosis. One study showed that about half the patients presenting with depression are not recognised at presentation. What is more, only a further 10% are subsequently recognised and 20% remit in this time. The remaining remained unrecognised even after 6 months. Another study found that general practitioners detected depression in only 36% of patients scoring highly in the General Health Questionnaire. Screening instruments can improve detection.
When to use – Based on national survey figures on adults aged 16-64 years of age we can expect 1600 women and 1100 men in the
It is important to be extra vigilant for depression in the following high risk groups: -
Those with: -
Ø
A previous history of depression
Ø
A family history of depression
Ø
Recent bereavement (or anniversary of bereavement)
Ø
Multiple adverse l
Ø
Chronic physical illness
Ø
Frequent attendance at surgery
The simplest screen for depression is the Two Question Test.
If the patient answers yes to these questions further assessment for diagnosis is indicated. The PHQ questionnaire would be an appropriate way to confirm the diagnosis objectively.
DIAGNOSIS
Diagnostic criteria
The ICD – 10 criteria for depression are
Diagnosis of moderate/severe depression may be made when a patient describes LOW OR SAD MOOD LOSS OF INTEREST OR PLEASURE REDUCED ENERGY Associated symptoms are frequently present • Disturbed sleep (Insomnia/ hypersomnia) • Worthlessness or guilt • Reduced concentration • Disturbed appetite (loss or increase of appetite/weight) • Suicidal thoughts or acts • Retardation or agitation • Symptoms of anxiety or nervousness • Reduced self esteem or self confidence • Bleak or pessimistic views of the future |
If written questionnaires are to be used in aiding diagnosis they must be completed in the surgery to be valid.
Most questionnaires are copyright to publishing companies or authors, even
For this reason we recommend the use Of the PHQ-9 as permission has been granted by Pfizer for its use in association with these guidelines.
The Patient Health Questionnaire (PHQ-9)
The Patient Health Questionnaire contains a brief, 9-item, patient self-report depression assessment spec
Patients should not be diagnosed solely on the basis of a PHQ-9 score.
The clinician should corroborate the score with clinical determination that a sign
In addition to its use as a diagnostic instrument, the PHQ-9 can also be used as a depression severity tool for monitoring treatment.
PATIENT HEALTH QUESTIONNAIRE – PHQ – 9
Patient Name:________________________ Date:___________________________
Not at all |
Several days |
More than half the days |
Nearly every day |
|
Score: |
0 |
1 |
2 |
3 |
a. Little interest or pleasure in doing things |
|
|||
b. Feeling down, depressed, or hopeless |
||||
c. Trouble falling/staying asleep, sleeping to much |
||||
d. Feeling tired or having little energy |
||||
e. Poor appetite or overeating |
||||
f. Feeling bad about yourself – or that you are a failure or have let yourself or your family down |
||||
g. Trouble concentrating on things, such as reading the newspaper or watching television |
||||
h. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual |
||||
i. Thoughts that you would be better off dead or of hurting yourself in some way |
Not d
Total Number of Symptoms:____________________ Total Score: ____________________
Reproduced with the permission of Pfizer Limited
Using PHQ-9 for Diagnostic Assessment
Of the 9 items in question 1, include only those that are checked at least “More than half the days”, except count the suicide item
At least one of item 1a or item 1b must be endorsed as more than half the days for a depression diagnosis. Also question 2 for functional impairment must be answered at least “Somewhat d
Using PHQ-9 for Severity of Depression Measure
Of the 9 items in question 1, using the score for each answer, sum the total for a severity score.
DIAGNOSTIC CATEGORIES FOR DEPRESSION
PHQ-9 Symptoms & Impairment |
PHQ-9 Severity |
Provisional Diagnosis |
Treatment Recommendations** |
1 to 4 symptoms, functional impairment |
< 10 |
<Mild or Minimal Depressive Symptoms |
Reassurance and/or supportive counselling Education to call |
2 to 4 symptoms, question a or b +, functional impairment |
10-14 |
Moderate Depressive Symptoms (Minor Depression)* |
Watchful waiting Supportive counselling If no improvement after one or more months, consider use of antidepressants or brief psychological counselling |
=/> 5 symptoms, questions a or b +, functional impairment |
15-19 |
Moderately Severe Major Depression |
Patient preference for antidepressant and/or psychological counselling |
=/> 5 symptoms, question a or b +, functional impairment |
>20 |
Severe Major Depression |
Antidepressants alone or in combination with psychological counselling |
·
*If symptoms present for >2years, Chronic Depression, or functional impairment is severe, remission with watchful waiting is unlikely, immediate active treatment indicated for moderate depressive symptoms (minor depression)
·
**Referral or co-management with mental health specialty clinician
Reproduced with the permission of Pfizer Limited
Any indication of suicide or self-harm should be followed by more detailed risk assessment.
Treatment recommendations d
Mild depression is defined by presence of two of the triad of low mood, loss of interest and reduced energy and two other symptoms over at least two weeks. (PHQ scores of 10- 14)
Moderate depression is defined by three to four features in addition to low mood, loss of interest and reduced energy, occurring for at least two weeks. (PHQ scores of 15-19)
Severe depression is usually marked by agitation or retardation and the patient may be reluctant or unable to describe other features in detail. Both social functioning and work performance are likely to be disrupted. (PHQ scores of > 20)
Mild depression should be treated by education and watchful waiting. Non-drug strategies are to be preferred to drug treatment.
In mild depression a period of watchful waiting is recommended. Regular appointments at two weekly intervals with the same GP will allow for progress or deterioration to be monitored. PHQ-9 can be readministered.
GPs should be confident of the proven efficacy of GP support and counselling and be positive about the benefits of giving time to depressed patients.
The high proportion of patients presenting with somatic symptoms means that often GPs will spend time excluding physical conditions, thereby gaining the patient’s trust and increasing understanding of their depression.
Patients may benefit from information on the nature of depression. Discussion between doctor and patient can help ensure a shared view of the illness. Talking to patients in terms of depression altering their thinking, feelings and behaviour as well as having physical effects can help clar
Patient education leaflets can be found at www.prodigy.nhs.uk/PILs
.
Listening is essential since often the problems cannot be solved, but talking about them may bring relief. It may be useful for people to have access to a confidential help line outside of surgery hours. Breathing Space provides such a service.
In depression people often overlook potential solutions to l
Self help web sites for people with mild depression/depressive symptoms can be found at www.livinglifetothefull.com
Reduced activity rates often result in people losing sources of pleasure and social contact. Discussion of ways to re introduce such stimulation can be helpful, as can ideas on reorganising work commitments and obligations in order to adjust to lowered capacity for decision making and activity.
Exercise has been shown to be beneficial for low mood. GPs can discuss exercise with patients and encourage them to take up a regular programme suited to their needs.
Unhelpful behaviours, such as drinking too much or excessive spending, may develop in an attempt to alter mood. A check for the presence of such maladaptive self “help” strategies may help prevent their escalation and reduce secondary l
Poor sleep can compound depression and d
A useful patient leaflet “Insomnia (Poor Sleep)” is available On-line at: - http://www.prodigy.nhs.uk/PILs/
Counselling is not spec
Other forms of psychological intervention such as anxiety management, relaxation training, stress management, assertiveness training are not contra-indicated and may be helpful for certain individuals.
These strategies are not a substitute for active treatment but they can be useful adjunct to it. Fact sheets giving details of local self help resources, telephone help lines etc; should be available in surgeries.
Moderate depression should be treated by anti-depressant medication and/or cognitive behavioural therapy. The latter might be provided through self help materials in the first instance.
Computerised/Book Based self help is available as for mild depression.
It may be useful for people to have access to a confidential help line outside of surgery hours. Breathing Space and Samaritans provides such a service.
Handouts for self help for depression are published in Overcoming Depression: A Five Areas Approach by Chris Williams, www.arnoldpublishers.com ,and linked training materials on www.calipso.co.uk
See later section for referral to Cognitive Behavioural Therapists
Severe depression requires anti-depressant medication and consideration of Referral to Mental Health Specialists. Risk assessment is essential.
Patients are more likely to implement advice
Contact at fortnightly intervals for moderate depression and initially weekly in severe depression should be considered, with contact remaining at 2-3 months intervals throughout treatment.
Psychiatry
Psychiatrists are happy and willing to see all patients with depression or any other psychiatric disorder
Community Mental Health Services
The structure of the Community Mental health Services varies throughout the Highlands and therefore there are local arrangements in place for referrals. Teams may compromise of Social Workers, Occupational Therapists and Community Psychiatric Nurses. They can offer a range of core skills such as assessment, treatment and care, outcome evaluation and health education. Some teams have specialists in Cognitive Behavioural Therapy. Community Mental Health Teams will consider referrals for any patient who is or is suspected to be suffering depression.
Consider referral to Community Mental Health
Ø
Is aged 16 or over and has left school
Ø
Is isolated and vulnerable
Ø
Has a previous history of mental health problems
Ø
Has thoughts of self harm and/or feelings of hopelessness
Ø
Abnormal grief reaction
Ø
Presents with multiple psychosocial problems
Ø
Has a history of poor coping skills
CBT is particularly suitable for those who
Development plans for Psychological Therapies across Highlands include the establishment of Cognitive Behaviour Therapists posts for each area. These should be coming on stream during the l
Psychologists accept referrals of patients with all forms of depressive d
1.
Duration of six months in spite of adequate drug therapy
2.
Refusal to use antidepressants/failure to respond to medication/other factors preventing drug treatment
3.
History of relapses/recurrent episodes
4.
Concurrent/alternative diagnosis or d
5.
Depression is part of a pattern of d
In order for patients to see a psychologist they need to be able to attend a clinic during working hours.
MoodGYM is a free, interactive internet-based program designed to prevent and decrease symptoms of depression.
MoodGYM aims to teach you how you can feel less stressed, depressed and anxious, and better able to cope with your l
From MoodGYM we hope you will learn helpful ways of thinking about problems, how to improve your self-esteem, and how best to relate to others (and to be more assertive). You will also learn how to increase the pleasure in your l
MoodGYM consists of a number of interactive modules. These should be completed in order, as each module builds upon material covered in earlier modules. As you move through the program, you will be presented with information, animated demonstrations, quizzes and ‘homework’ exercises.
Your answers to the exercises are recorded in your own personal MoodGYM Workbook.
The Workbook is important as it helps you track your progress as you move through the modules.
Think of MoodGYM as an interactive self-help book. There are many books about how to improve your mental health.
The advantage of MoodGYM is that it can give you feedback about your mental health, and you can use the online exercise to work out how to handle l
Moodgym is located at http://moodgym.anu.edu.au
Living L
The Living L
The modules act as a free and stand-alone resources to be worked through at home in the person's own time. They may sometimes be supported by sessions with a health care practitioner. The materials use modern educational techniques and the evidence-based cognitive behaviour therapy (CBT) approach to help bring about helpful change.
Living L
Breathing Space is a free, confidential phone line you can call when you’re feeling down. You might be worried about something – money, work, relationships, and exams – or maybe you’re just feeling fed up and can’t put your finger on why.
Sharing your feelings with your friends or talking with your family can be d
That’s when you might want to talk to the people at Breathing Space. They’re available to listen to you when you’re feeling low. They can offer advice, or suggest people who can help you with more spec
There are people at Breathing Space to listen to you every night from 6pm-2am, when you’re wide awake and running over problems in your mind.
The service is completely confidential and it’s a free phone number – 0800 83 85 87 (Minicom: 0800 31 71 60) – so it won’t show up in your phone bilss*.
So the next time you’re feeling down, it might help to get some Breathing Space.
*If you’re calling from a mobile, check out what you have with them – they might charge you for your call.
http://www.breathingspacescotland.co.uk
Samaritans'
Samaritans is available 24 hours a day to provide confidential emotional support for people who are experiencing feelings of distress or despair, including those which may lead to suicide.
In the UK dial 08457 90 90 90, for the cost of a local call.
Antidepressants in Pregnancy and Breast-feeding
Patients with low mood or loss of interest plus at least four of the other diagnostic features mentioned are most likely to respond to drug treatment. For these patients with moderate to severe depression, antidepressants should be considered the mainstay of treatment.
Antidepressants are effective in the treatment of moderate to severe depression. However, antidepressants do not appear more efficacious than placebo in milder depression and are not recommended for the initial treatment of mild depression. In milder depressive states non-drug strategies are often preferable to drug treatment.
The fact that a patient’s depression is “understandable” should not deter the GP from prescribing antidepressants since they are just as likely to be effective. 70% of patients are likely to respond to the first intervention offered.
All antidepressants have broadly similar efficacy (Song et al 1993) and therefore the choice of drug for a particular patient will depend on the nature of the symptoms, side-effect profile, concomitant therapy, concurrent illness, patient preference and safety in over-dose. Previous response to treatment is also a strong indication to repeat that treatment in future episodes.
The antidepressant whose profile best fits the ideal for an individual patient should be prescribed. In the absence of special factors, choose antidepressants which are better tolerated, safer in overdose, and more likely to be prescribed at effective doses. Since there is most evidence for SSRIs, they should be regarded as the preferred option for first line use.
When prescribing an SSRI, fluoxetine is a reasonable choice as it has efficacy similar to other SSRIs, but is available as a generic, and hence provides additional benefit in terms of cost effectiveness.
When considering toxicity in overdose, the evidence to date suggests that SSRIs, newer tricyclics, mirtazapine and reboxetine are safer than older tricyclics or venlafaxine.
The newer agents may have a place in treatment of patients for whom first choice drugs are poorly tolerated or ineffective.
The cost of these drugs should also be taken into account when a decision is made to prescribe, especially when choosing between drugs in the same class.
Antidepressants account for a large proportion of the primary care drugs spend.
TCAs are by far the cheapest agents, especially compared to newer antidepressants, but they carry the risk that they may be prescribed in sub-therapeutic doses, e.g. to avoid adverse effects which are common with TCAs. Generic SSRI preparations such as fluoxetine offer a safer but relatively inexpensive alternative.
The same principals apply to the elderly as the adult population in the decision on which antidepressant to use. Concomitant therapy and concurrent illness are likely to be of greater relevance.
The main d
SSRIs can usually be started at a therapeutic dose.
TCAs should be gradually increased to the therapeutic dose over 1-2 weeks, or as quickly as can be tolerated.
Patients should be advised of the likely early side effects, and the lag time before symptoms noticeably improve.
Increased anxiety/agitation can be problematic at the early stages of treatment with an SSRI. Judicious short-term use of a benzodiazepine may be helpful in such situations.
CSM Advice Hyponatraemia (usually in the elderly and possibly due to inappropriate secretion of antidiuretic hormone) has been associated with all types of antidepressants and should be considered in the d |
Compliance Issues
Compliance with prescribed medication for all chronic conditions is estimated at 50%. There are a variety of reasons why patients cannot or will not comply with their prescribed medication, but there are particular reasons why compliance may be a problem with antidepressants.
Before starting treatment compliance can be improved by
Community Pharmacists are usually pleased to offer advice to patients on antidepressants.
Drug Group |
Description |
Suggested Drug |
Serotonin Selective Reuptake Inhibitors |
Recommended for first line use, especially in older or physically ill patients, more susceptible to side effects. They are better tolerated than TCAs and are more likely to be prescribed at adequate doses for an adequate period. (Rosholm et al 1997). Fewer anticholinergic and cardiovascular side effects than TCAs. Are not without side effects. These are mainly gastrointestinal e.g. nausea, diarrhoea. |
Fluoxetine |
Tricyclic Antidepressants (TCA) |
Use at adequate dosage often limited by side effects. Anticholinergic side effects e.g. constipation, blurred vision and dry mouth are common. Cardiovascular effects such as arrhythmias and hypotension can also occur. TCAs can prolong the QT interval. Sedation can be problematic but may also be useful in some patients. Tolerance to some side effects can develop but may necessitate gradual dosage increases. Amitriptyline is comparable in efficacy and safety to other TCAs but is recommended, as it is more cost effective. |
Amitriptyline |
Serotonin Norepinephrine Reuptake Inhibitor (SNRI) |
Not for first line use. NICE recommend initiation and monitoring under specialist supervision only. May have greater efficacy than SSRIs at doses of 150mg or greater. Dose responsive so can titrate dose for further effect. Side effect profile similar to SSRIs but can lower/elevate blood pressure. Note requirement for pre-treatment ECG and B.P. check. |
Venlafaxine |
Norepinephrine and Serotonin Spec |
Not for first line use. Weight gain can be a problem. Low incidence of sexual dysfunction. May potentiate other centrally acting sedatives. Suitable for patients who require sedation but for whom a TCA is not suitable. |
Mirtazepine |
Norepinephrine Reuptake Inhibitor (NARI) |
Normally used after consultation with secondary care. Is not sedating but insomnia can be a problem, along with some anticholinergic side effects. |
|
Monoamine Oxidase Inhibitor (MAOI) |
Normally used after consultation with secondary care. |
Phenelzine |
Normal recommended dose range for the ten most frequently prescribed antidepressants in Highland in 2002-3 are shown below. Please see NHS Highland Joint Formulary for currently recommended antidepressants.
SSRIs Fluoxetine Citalopram Paroxetine Sertraline NEWER ANTIDEPRESSANTS Venlafaxine** Mirtazapine OLDER TCAs Amitriptyline Clomiprammine Dosulepin NEWER TCAs Trazodone |
ADULTS 20mg 20-60mg 20-50mg* 100-200mg 75-375mg 15-45mg 150-200mg 150-200mg 150-225mg 200-300mg |
ELDERLY 20mg 20-40mg 20-40mg 50-200mg 75-375mg 15-45mg Not Recommended 150-300mg |
*Note CSM 2004 advice. Recommended dose for depression is 20mg
**Applies only to the immediate release preparation
Failure to respond despite good compliance
• No response after 4 weeks
• Partial response after 4 weeks, continue for a further 2 weeks. Partial response converted to full response at 6 weeks?
• No response after 6 weeks
• Partial response after 6 weeks, continue for a further 3 weeks. Partial response converted to full response at 9 weeks?
If a full response is not obtained within the time scales outlined above then:
• First increase the dose of the current antidepressant to the upper limit of the therapeutic range, provided the patient can tolerate any side effects.
• Switch to a drug of a d
MAOIs, TCAs and SSRIs include SNRI, NARI, and NaSSAs. Call Pharmacy Department at
New Craigs Hospital for advice
• Washout periods are required for switching between certain antidepressants (see below)
Antidepressant Swapping – General Guidelines
1.
Fluoxetine, due to its long plasma half-l
2.
When swapping from one antidepressant to another, abrupt withdrawal should usually be avoided. Cross tapering is preferred, where the dose of the ineffective or poorly tolerated drug is slowly reduced while the new drug is slowly introduced.
3.
The speed of cross tapering is best judged by monitoring patient tolerability. No clear guidelines are available, so caution is required.
4.
Note that the co-administration of some antidepressants is absolutely contra-indicated. See BNF Chapter 4.3.2 and Appendix 1. In other cases, theoretical risks or lack of experience preclude recommending cross tapering.
5.
Withdrawal ideally involves a gradual reduction to a low dose of antidepressant before stopping.
6.
Potential dangers of simultaneously administering two antidepressants include pharmacodynamic interactions (serotonin syndrome, hypotension and drowsiness) and pharmacokinetic interactions (e.g. elevation of tricyclic plasma levels by some SSRIs).
FROM |
Tricyclics |
Citalopram |
Fluoxetine |
Paroxetine |
Sertraline |
Trazodone/ nefazodone |
Venlafaxine |
Mirtazapine |
Reboxetine |
Tricyclics |
Cross taper cautiously |
Halve dose and add citalopram then slow withdrawal. ** |
Halve dose and add fluoxetine then slow withdrawal. ** |
Halve dose and add paroxetine then slow withdrawal. ** |
Halve dose and add sertraline then slow withdrawal. ** |
Halve dose and add trazodone/ nefazodone then slow withdrawal. ** |
Cross taper cautiously starting with venlafaxine 37.5mg at night |
Withdraw before starting mirtazapine cautiously |
Cross taper cautiously |
Citalopram |
Cross taper cautiously. ** |
- |
Withdraw then start fluoxetine. |
Withdraw and start paroxetine at 10mg/day |
Withdraw and start sertraline at 25mg/day |
Withdraw before starting titration of trazodone/ nefazodone |
Withdraw. Start venlafaxine 37.5mg/day. Increase very slowly |
Withdraw before starting mirtazipine cautiously |
Cross taper cautiously |
Paroxetine |
Cross taper cautiously with low dose of tricyclic.** |
Withdraw and start citalopram |
Withdraw then start fluoxetine |
- |
Withdraw and start sertraline at 25mg/day |
Withdraw before starting titration of trazodone/ nefazodone |
Withdraw paroxetine. Start venlafaxine 37.5mg/day and increase very slowly |
Withdraw before starting mirtazipine cautiously |
Cross taper cautiously |
Fluoxetine*1 |
Stop fluoxetine. Start tricyclic at very low dose and increase very slowly |
Stop fluoxetine. Wait 4-7 days. Start citalopram at 10mg/day and increase slowly |
- |
Withdraw fluoxetine. Wait 4-7 days, then start paroxetine 10mg/day |
Stop fluoxetine. Wait 4-7 days. Start sertraline at 25mg/day |
Stop fluoxetine. Wait 4-7 days. Start low dose trazodone/ nefazodone |
Withdraw. Wait 4-7 days. Start Venlafaxine at 37.5mg/day. Increase very slowly. |
Withdraw. Wait 4-7 days before starting mirtazapine cautiously |
Withdraw. Start reboxetine at 2mg bd and increase cautiously |
Sertraline |
Cross taper cautiously with very low dose of tricyclic. ** |
Withdraw then start citalopram |
Withdraw then start fluoxetine |
Withdraw then start paroxetine |
- |
Withdraw before starting trazodone/ nefazodone |
Withdraw. Start venlafaxine at 37.5mg/day |
Withdraw before starting mirtazapine cautiously |
Cross taper cautiously |
Trazodone/ nefazodone |
Cross taper cautiously with very low dose of tricyclic. |
Withdraw then start citalopram |
Withdraw then start fluoxetine |
Withdraw then start paroxetine |
Withdraw then start sertraline |
- |
Withdraw. Start venlafaxine at 37.5mg/day |
Withdraw before starting mirtazapine cautiously |
Withdraw, start reboxetine at 2mg BD and increase cautiously |
Venlafaxine |
Cross taper cautiously with very low dose of tricyclic. ** |
Cross taper cautiously. Start with 10mg/day |
Cross taper cautiously. Start with 20mg every other day |
Cross taper cautiously. Start with 10mg/day |
Cross taper cautiously. Start with 25mg/day |
Cross taper cautiously |
- |
Withdraw before starting mirtazapine cautiously |
Cross taper cautiously |
Mirtazapine |
Withdraw then start tricyclic |
Withdraw then start citalopram |
Withdraw then start fluoxetine |
Withdraw then start paroxetine |
Withdraw then start sertraline |
Withdraw then start trazodone/ nefazodone |
Withdraw then start venlafaxine |
- |
Withdraw then start reboxetine |
Reboxetine |
Cross taper cautiously |
Cross taper cautiously |
Cross taper cautiously |
Cross taper cautiously |
Cross taper cautiously |
Cross taper cautiously |
Cross taper cautiously |
Cross taper cautiously |
- |
** Do not co-administer clomipramine and SSRIs or venlafaxine. Withdraw clomipramine before starting
*1 Beware interactions with fluoxetine may still occur for five weeks after stopping fluoxetine because of long half-l
Serotonin Syndrome – Symptoms
Restlessness
Sweating
Tremor
Shivering
Myoclonus
Confusion
Convulsions
Death
Inadequate or no treatment for six months after the illness has resolved can result in relapse rates as high as 50%.
Continue antidepressant drug treatment for a minimum of 6 months after remission of symptoms in adults, and for a minimum of 12 months in the elderly.
Continue the same dose of antidepressant used that produced a response to treatment.
Patients with residual depressive symptoms and other factors increasing risk of relapse should continue treatment for longer with the duration taking into account the persistence of these factors.
The risk of recurrence of depressive illness is high and increases with each episode.
Maintenance therapy should be at the same dose of antidepressant that produced a response to treatment.
The decision to go on to maintenance therapy, rather than stop treatment at the end of the continuation phase, must be made on clinical grounds in discussion with the patient. Maintenance treatment with antidepressants is indicated for patients with:
Re-evaluate patients on maintenance treatment, taking into account age, co morbid conditions and other risk factors in the decision to continue the treatment beyond 2 years.
For the elderly, with two or more relapses, l
Discontinuation symptoms can occur with all the major classes of antidepressant
Symptoms start abruptly within a few days of stopping the antidepressant
Symptoms usually resolve with days to 3 weeks
Risk factors: longer duration of treatment, short half l
If administered for 8 weeks or more, antidepressants should be reduced gradually over a minimum of 4 weeks. Fluoxetine may be an exception to this rule. Rapid discontinuation may be required for severe adverse reactions or
Ideally taper the dose over 6 months in patients who have been on longer-term maintenance treatment
If discontinuation symptoms are mild then explanation and reassurance are often all that is required
If severe symptoms are experienced consider the re-introduction of the original antidepressant (or another from the same class with a longer half l
Discontinuation symptoms are varied and d
Updated advice in these areas can be obtained locally from the Area Medicines Information Service (Tel. 01463 704288) or New Craigs Pharmacy Department (01463 704663).
Carefully consider the benefit/risk ratio of prescribing antidepressants during pregnancy and breastfeeding for both mother and baby/foetus. Taking into account:
a.
Antidepressants are not licensed for use in pregnancy & breastfeeding.
b.
There should be a clear indication for drug treatment
c.
Lowest effective dose should be given for the shortest period necessary
d.
Drugs with a better evidence base (generally more established drugs) are preferable.
Evidence indicates no increased risk of major malformation or spontaneous abortion following exposure to TCAs or SSRIs in early pregnancy. There is most evidence for amitriptyline and imipramine in the TCA class, and most evidence for Fluoxetine in the SSRI class.
·
Carefully assess the risks of stopping TCAs or SSRIs in relation to the mother’s mental state & previous history
·
There is no indication to stop TCAs or SSRIs as a matter of routine in early pregnancy
·
If a woman becomes depressed during pregnancy, antidepressants should be prescribed with caution and specialist advice sought
In later pregnancy there is evidence of neonatal toxicity and withdrawal at birth in infants exposed to antidepressants. There are also concerns about the possible effects on infant neurodevelopment.
·
Neonates exposed to antidepressants during pregnancy should be monitored for withdrawal following delivery
·
Consider dose reduction and/or discontinuation 2 to 4 weeks before expected delivery date then recommence after delivery.
Antidepressants during breast-feeding
Manufactures advise avoiding antidepressants during breast-feeding due to their excretion in breastmilk and the evidence base is very limited. However there is no clinical indication for women treated with TCAs (except doxepin) or the SSRIs paroxetine, sertraline or fluoxetine to stop breast-feeding provided the infant is healthy and progress is monitored.
·
Breast-feeding should take place immediately prior to taking medication, ideally as a single daily dose just before the infant’s longest sleep period
·
Ideally avoid breast feeding when maternal plasma levels are highest, usually 1 to 2 hours after taking the medication
·
Paroxetine or Sertaline may be the preferred SSRIs.
A patient information leaflet concerning antidepressants and breastfeeding has been produced by NHS Highland. This is written in plain English and is designed to assist the GP in enabling the patient to come to an informed decision.
When initiating treatment in patient with ischaemic heart disease, sertraline is the treatment of choice.
When a patient has declined a number of offers of treatment for depression or expressed a preference for St John’s Wort they should be informed that St John’s Wort may be of benefit in mild and moderate depression. They should also be informed, as should those taking St John’s Wort, of the interactions of St John’s Wort with other drugs, of the lack of information on longer term efficacy and side effects and of the d
Always check
When a diagnosis of Depression is made, suicide risk requires assessment. For all depressed patients the following questions may be asked:
·
Have these symptoms/feelings we've been talking about led you to think you might be better off dead?
·
This past week, have you had any thoughts that l
·
What about thoughts about hurting or even killing yourself? If YES, what have you thought about?
Have you actually done anything to hurt yourself?
ASSESSMENT OF SUICIDE RISK
Risk |
Description |
Action |
Low Risk |
No current thoughts, no major risk factors * See risk factors above |
Continue follow-up visits and monitoring |
Intermediate Risk |
Current thoughts, but no plans, with or without risk factors |
Assess suicide risk carefully at each visit and contract with patient to call you |
High Risk |
Current thoughts with plans |
Emergency assessment by qual |