Psychiatric perspectives Flashcards
What are the current depression treatment options?
> Pharmacological
- antidepressants and adjunctive treatments
> Non-pharmacological
- psychotherapy (CBT, IPT, psychodynamic)
- lifestyle changes and minfulness
- phototherapy (use of bright light)
> Neurostimulation
- ECT
- Deep brain stimulation (DBS)
- Vagus nerve stimulation
- Repetitive Transcranial Magnetic Stimulation (rTMS)
What is the use of phototherapy?
Helpful for seasonal and non-seasonal affective disorders
Are the current treatments for depression exclusive?
No
- psychological + pharmacological therapy
What is the history of use behind antidepressants, antipsychotics and anti-convulsants?
Derived form other areas of medicine, then repurposed for mood disorders,
with sound evidence base
What do the rates of antidepressant prescriptions in England (2015) tell us?
2015: 61 million prescriptions written
- 8-10% receiving antidepressants
-> frequently used medication
What is the goal of treating depression?
Remission
What is remission?
Reduction of symptoms below a certain level
- less than 8 on HAM-D scale
- less than 10 on MADRS scale
- less than 5 on QIDS-SR
What is a response to treatment?
50% reduction in symptoms from baseline QIDS-SR
- self-inventory
- designed to measure severity of depressive symptoms
- based on DSM-IV
-> Measure of signal of efficacy rather than satisfactory treatment outcome
Why are residual symptoms relevant?
> Patients associated with higher residual symptoms have poorer outcomes and higher relapse rates compared to those without
> Residual symptoms associated with early relapse, even mild residual symptoms
What was the goal of the STAR*D study?
Set benchmark for our expectations of treatment
- STAR*D algorithm (Sequence Treatment Alternatives to Relieve Depression)
What did the STAR*D study consist of?
> Carried out in early 2000s in the US
- headed by Pr. John Rush
> Multi-level progressive treatment algorithm
- Level 1: initial treatment: citalopram
- Levels 2, 2A, 3
- Level 4: switch to tranylcypromine or mirtazapine combined with venlafaxine (extended-release)
What did the STAR*D study (2007) show?
> Implementing all of the treatment strategies in the algorithm resulted in:
- 2/3 participants remitting
- 1/3 participants with persisting depressive symptoms
> Failure to achieve remission increased risk of relapse
> Switching treatment does not have to be within same class to have extra benefit
What are the current identified problems with antidepressants?
> Majority of patients with depression do not respond to, or do not achieve remission through first pharma treatment applied
> Chance of achieving remission reduces with each new treatment attempts
> Risk of relapse increases with each new treatment
What can be done if a patient does not remission?
- Reconsider the diagnosis
- Evaluate patient’s adherence to treatment
- Consider increasing the dosage
- Change treatment
- Augment the treatment (adjunctive medication)
What is the evidence on increasing the dosage of an antidepressant?
Limited evidence, but should be considered especially if:
- there are minimal side-effects
- some improvement on the antidepressant
- current antidepressant has possible dose response
- evidence for venlafaxine, escitalopram and TCAs
When should you consider switching antidepressants?
> If there are troubling or dose-limiting side-effects, and/or no improvement
> Switch within or between antidepressant classes initially
> Consider different class after more than one failure with a specific class
e.g. Failure on 2 SSRIs -> first consider SNRI or other class, then consider venlafaxine
When should you avoid switching antidepressant quickly?
- If there’s potential drug interaction
- If there are potential drug discontinuation effects
Which antidepressants have evidence of higher efficacy?
- Venlafaxine (> 150mg)
- Escitalopram (20mg)
When should you consider augmenting/combining pharmacological treatment?
> If there’s partial/insufficient response on current antidepressant but good tolerability
> If switching antidepressants has been unsuccessful
What is necessary when augmenting/combining pharmacological treatments?
> Establish the safety of the proposed medication
> Choose the combination(s) with best evidence base first
What did the CO-MED stud (Rush et al., 2011) show?
No significant benefits of combining antidepressants
What are the guidelines for the augmentation of antidepressants?
> Consider adding an atypical antipsychotic
- Quetiapine
- Aripiprazole
> Consider adding lithium (monovalent cation)
> Other antipsychotics may be considered
- Risperidone
- Olanzapine
- Trlodothyronine
- Mirtazapine
What is the evidence on the switching or augmentation of antidepressants in older patients?
- Smaller evidence base
- About 50% respond to switching or augmentation
- Best evidence for lithium augmentation
What are the guidelines on augmenting antidepressants for severely treatment resistant patients?
Consider
- multiple combinations concurrently
- approaches with limited evidence
- must be carried out in specialist centres with appropriate expertise and safeguards
