Management of Depression

Question 1

What general measures should be discussed if someone has subthreshold depressive symptoms or mild to moderate depression?

Answer 1

1. Sleep hygeine
2. Acitve monitoring for people who do not want an intervention.
   
   • Arrange further assessment in 2 weeks.
   • Contact them if they do not attend follow up appointments.

Question 2

What should the preferred method of treatment be for subthreshold depressive symptoms or mild depression?

Answer 2

Low intensity psychosocial interventions

Question 3

What are the low intensity psychosocial interventions are receommended for subthreshold depressive symptoms or mild depression?

(Based on patient preference)

Answer 3

1. Individual guided self help based on CBT principles.
   
   • Include written materials.
   • Be supported by a trained practitioner who reviews progress.
   • Consist of up to 6-8 sessions over 9-12 weeks including follow up.
2. Computerised CBT - take place over 9-12 weeks including follow up. (Beating the Blues)
3. A structured group physical activity prgramme:
   
   • Typically 3 session per week lasting 45minutes to 1 hour over 10-14 weeks.
4. Group based CBT- 10-12 meetings of 8-10 participants. 2 trained practitioners. Typically take place over 12-16 weeks includingfollow up.
5. Group Based Peer Support Programme (if chronic health problems) - 1 session a week for 8-12 weeks

Question 4

Should antidepressants be used in subthreshold depressive symptoms or mild depression?

Answer 4

Generally No. But consider them in the following:

1. A past history of moderate or severe depression
2. Initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years)
3. Subthreshold depressive symptoms or mild depression that persist(s) after other interventions
4. If a patient has a chronic physical health problem and mild depression complicates the care of the physical health problem

Question 5

In what year were the NICE guidelines for depression produced?

Answer 5

2009

Question 6

Describe NICE’s 3 Step process of treating depression.

Answer 6

Step 1 - Assessment, recognition and initial management.

Step 2 - Treating persistent subthreshold depressive symptoms or mild to moderate depression

Step 3 - Treating persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression.

Step 4 - Complex and severe depression.

Question 7

If anxiety and depression are both present, which should you treat first?

Answer 7

Depression.

Question 8

What is the management strategey in Step 3

( moderate to severe depression or step 2 with no response.).

Answer 8

Start an antidepressant (SSRI) +/- high-intensity psychological intervention.

1. Start an SSRI
   
   • First line : Fluoxetine (NOTE: Fluoxetine has more drug-drug interactions)
   • Second line : Sertraline if no improvement.
   • If at risk of overdose, give sertraline.
   • Mirtazepine if fluoxetine and sertraline don’t help.
   • Add on quietiapine can help.
2. High Intensity psychological intervention.

Question 9

Name some types of high intensity psychological intervention

Answer 9

• CBT
• Interpersonal therapy (IPT)
• Behavioural activation (but note that the evidence is less robust than for CBT or IPT)
• Behavioural couples therapy for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit.
• Can also consider
  
  • Short term psychodynamic psychotherapy, counselling if subthreshold,mild or moderate.

Question 10

If elderly people are given SSRIs, what should be co-prescribed?

Answer 10

PPI

Question 11

Which SSRI is associated with a higher incidence of discontinuation symptoms than other SSRIs and why?

Answer 11

Paroxetine

Venlafaxine too.

They have a short half life and thus need a more gradual reduction.

Question 12

How do you stop an SSRI?

Answer 12

Gradually reduce over 4 weeks.

But with venlafaxine and paroxetine do it over a longer period.

Question 13

Do you need to gradually reduce when stopping fluoxetine?

Answer 13

No. You can stop it straight away due to its long half life.

Question 14

Which SSRIs are associated with more drug interactions?

Answer 14

• Fluoxetine
• Fluvoxamine
• Paroxetine

Question 15

What kind of follow up should be considered for people with depression?

Answer 15

2 weeks

(1 week if <30years or high risk of suicide)

Then 2-4 weekly intervals thereafter in the first 3 months.

And then longer intervals after that.

Question 16

Which medications have greater side effects and thus have poor compliance?

Answer 16

TCAs, Venlafaxine and duloxetine have greater side effects and so more likely to suddenly stop.

Question 17

What medication, in higher doses, can cause cardiac arrhythmias?

Answer 17

Higher doses of venlafaxine can exacerbate cardiac arrhythmias and the need to monitor the person’s blood pressure

Question 18

Which SSRIs can exacerbate hypertension?

Answer 18

Venlafaxine and Duloxetine

Question 19

When should you consider switching antidepressants or increasing the dose?

Answer 19

If no improvement by 2-4 weeks then switch or increase.

If no response by 6-8 weeks the switch.

Question 20

If a patient has chronic health problems what sort of high intensity psycholoogical intervention should they be offered?

Answer 20

• Group-based CBT
• Individual CBT

Question 21

What is the management strategy in Step 4 (Severe or complex depression)?

Answer 21

Refer to specialist mental health services

Question 22

What should your strategy be for switching antidepressants?

Answer 22

• Done within 1 week if short half life (Paroxetine, sertraline or venlafaxine)
• Take alternate days then after 1/52 start other SSRI.
• Fluoxetine needs a longer washout period due to it’s longer half life.

Question 23

If a patient is taking an SSRI and after 3-4 weeks is not noticing any particular benefit, what are your options?

Answer 23

1. Increase the dose of the current antidepressants
2. Change to an alternative agent if there are side effect or the patient prefers.