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
What is the evidence on augmenting antidepressant treatment with second-generation (atypical) antipsychotics?
Good evidence suggesting this should be a principal strategy for patients who haven’t responded to antidepressant monotherapy
What is the evidence on the effectiveness of lithium compared to augmenting antidepressants with atypical antipsychotics?
When we add lithium to antidepressants, aim for blood level of minimum 0.6 mmol/L to maximise likelihood of response
Otherwise:
lithium+antidepressants is less efficacious than quetiapine+antidepressants
(evidence is not robust)
What are the next-step physical treatment options for treatment resistant patients who failed to respond to a combination of lifestyle, psychological and pharmacotherapy options?
> ECT
- first-line physical treatment
> tDCS (transcranial direct current stimulation)
- limited evidence of efficacy in resistant patints
- not recommended in routine clinical practice
- being examined in clinical trials
> rTMS
- limited evidence of efficacy
- could be considered for those who are intolerant to other treatments
- limited availability
> Vagus nerve stimulation (VNS)
- commonly used for epilepsy
- limited but growing evidence of efficacy
> Deep brain stimulation (DBS)
- implanted electrodes in brain
- first used to treat Parkinsonism
- 2 trials that failed
> Ablative surgery
- less than a dozen patients per year in the UK undergo this treatment
When should vagus nerve stimulation be undertaken for treatment-resistant patients?
- Only in specialist centres with prospective outcome evaluation
- If long-term follow-up is available
When is deep brain stimulation (DBS) be recommended?
Only for use in very specialist centres as part of ongoing research
