Week 7- Treatment of depression, patient counselling and Special Patient Groups Flashcards
how many steps are part of the stepped-care model for treating depression?
4 steps
What is step 1 for treatment of depression?
- need for assessment
- support
- psycho-education of depression
- active monitoring
- onwards referral for further assessment and interventions
What is step 2 for treatment of depression?
- low intensity psychological or psychosocial interventions
- medication
- onwards referral
what is step 3 for treatment of depression?
- medication
- high intensity psychological interventions
- combined treatments and collaborative care
- onward referral
what is step 4 for treatment of depression?
- medication
- high intensity psychological interventions
- ECT (electroconvulsive therapy)
- crisis service
- combined treatments
- mutli-proffesional inpatient care
what are some non-pharmacotherapy treatments for depress?
initial steps and for low intensity
- social support (very important)
- guided self help
- being active
- computer based CBT
high intensity
- psychologoical therapy, CBT, COUNSELLING, RELAXATION THERAPY
- general support and advice e.g to help reduce stress
why dont you prescribe anti-depressants to treat mild depression?
due to poor risk-benefit ratio
who should be prescribed anti-depressants for mild depression?
Past history of moderate-severe depression
Persistent subthreshold depressive symptoms for >2 years
Mild depression persists following other interventions
what should the choi8ce of anti-depressant be based on?
Duration of episode
Previous antidepressant response
Likelihood of adherence, potential adverse effects, patient preference
what type of dose is first used for anti-depressants?
Almost all antidepressants ( with exception of Mirtazapine) are more tolerable if started at a lower initial dose (half the standard) and increased to the target dose over a few days or weeks
what are the first line treatment for anti-depressants?
SSRI
why are tricyclics difficult to get to the therapeutic dose?
due to wide range of side effects giving poor tolerability
what is done if a patient doesn’t respond to several anti-depressants? what needs to be considered?
combination known as augmentation where you:
- combine other antidepressant
- combine with lithium used for persistent depression
- combine a antipsychotic
- be aware of side effects and monitoring requirements
- some of the antipsychotic choices are Aripiprazole, Olanzapine, Quetiapine or Risperidone
what does SSRI stand for?
selective serotonin reuptake inhibitor
what are some examples of SSRI for depression?
- citalopram 20-40mg/d
- escitalopram 10-20mg/d
- fluoxetine 20mg/d
- sertraline 50-100mg/d
- Venlafaxine 75-375mg/d normally reserved for resistant depression
- vortioxetine 10-20mg/d
- quetiapine 150-300mg/d
what is the dose time for SSRI?
in the morning
-mirtazapine taken at night
what type of drug is agomelatine?
Agomelatine is a melatonin receptor agonist and
improves sleep
what is the onset of action of anti-depressants? no improvement what to do?
- take 2-6 weeks to work, although some may see benefit after 1 wk
- at patient review after 4wks if there’s no improvement in patients mood, switch to another anti-depressant
- elderly may need increase
- patient should be seen every 2-4wks by GP for first 3 month for adults
how do you go about switching patients on anti-depressants?
-initially try another SSRI or better tolerated newer-generation anti-depressant
- If tolerance is the issue try a different mode of action, chemical group, or from
same group
- If lack of efficacy is the problem try a different class or mode of action
-Cross-taper SSRI/SNRIs carefully to avoid serotonin syndrome
- Tricyclics can interact with some SSRIs
what are some cautions when switching antidepressant?
• CAUTION!- FROM Fluoxetine to other antidepressants, because Fluoxetine has a
long half-life
• CAUTION!- FROM Fluoxetine to reversible MAOI (e.g Moclobemide)- Taper and stop
Fluoxetine and wait 5-6 weeks
• CAUTION!-FROM a non-reversible MAOI: a 2-week washout period is required
is mirtazapine a good antidepressant and easy to switch to and from?
Mirtazapine improves sleep, can be used in combination and is an easy to use
antidepressant to switch to and from
what needs to happen if 2 failed antidepressants at adequate dose and duration?
needs a review of the diagnosis e.g. bipolar depression
what is serotonin syndrome?
- it is serious drug reaction,
- It is caused by medications that build up high levels of serotonin in the body.
what are symptoms of serotonin syndrome?
- Restlessness
- Myoclonus
- Tremor and rigidity
- Hyperreflexia
- Shivering/elevated temperature
- Arrhythmias
what can cause cardiac collapse?
serotonin syndrome due to combination of serotonergic drugs like SSRI, SNRI, Tramadol, Triptans
what is the duration of treatment for depression?
- continue for as long as needed to reduce relapse
- after first episode, 6months after recovery at same dose minimises risk of relapse
- second episode, 1-2 years may reduce relapse
- 3rd or subsequent episode, 3-5 yrs or longer significantly reduces relapse
when is there a potential risk of suicide and self-harm when using anti-depressants?
within the first month
what can occur if antidepressants are stopped sudden?
antidepressant discontinuation or withdrawal and symptoms can occur with 1-3 days of stopping/reducing dose (not fluoxetine due to long half life can take upto 3wks)
when are antidepressant discontinuation or withdrawal symptoms suppressed?
when drug is re-introduced into the body
when will you get antidepressant discontinuation or withdrawal symptoms?
- stopping
- reducing dose
- missed dose for some
what are some of the anti-depressant such as SSRIs discontinuation/withdrawal symptoms?
-dizziness, light-headedness
-sleep disturbances
-agitation
electric shock feeling in the head
-nausea, fatigue, headache
-‘flu-like’ symptoms
what are some of the anti-depressant such as SNRIs (VENLAFAXINE,DULOXETINE discontinuation/withdrawal symptoms?
- as for SSRI
- restlessness
- abdominal distension
- congested sinueses
what is some advice for discontinuing antidepressants?
-Avoid stopping while still in the higher relapse risk time period -For less than 8 weeks treatment, withdraw stepwise over 1-2 weeks -After 6-8 months treatment, taper over a 6-8 week period -After long-term maintenance treatment, reduce the dose by 25% every 4-6 weeks
what is some practical advice and strategies for optimising treatment?
Counselling points:
-Start at a lower dose (to minimise side effects)
-side effects can be managed e.g. nausea, anticholinergic, anxiety,
weight, sexual
-Antidepressants are not addictive but treat them with respect
-Antidepressants may start to work in a few days or weeks but the
full effect may take about 4-6 weeks to reach optimum
-Duration of treatment will depend on the individual
-Reassure about long term use
why do SSRI cause nausea?
due to the serotonin receptors in the stomach
what is some advice for a patient experiencing anticholinergic effects? what SE
- Blurred vision- DONT DRIVE, normally wears away if not switch or adjust dose
- constipated- fibre, drink enough water, keep active, laxative e.g. lactulose
- dry mouth- suck boiled sweets or wine gums (not too many=weight)
- urinary retention- immediate medical emergency may be needed
what are some advice for managing side effects affecting central area?
- anxiety, start low doses and increase step-wise over several weeks or longer
- seizures, rare, need to change or much slower titration
- confusion, rare, usually need change or much slower titration.
- headache, try paracetamol
- insomnia+sleep disturbance, take dose in the morning not at night, split dose
- nausea, take with or just after food
- sleepiness or sedation, antihistaminic effect, dont drive
- suicidal ideation, in the next day especially if they are under about 20yrs or have bipolar depression
what are some advice for managing side effects affecting other areas?
- hyponatraemia (low levels of sodium), symptoms such as tiredness, confusion, headaches
- postural hypotension, try not to stand up too quickly, don’t drive, have blood pressure checked
- palpitations, beta-blocker if needed
- sexual dysfunction
- sweating, dose adjustment may be possible
- weight gain, a diet full veg, cereal and fibre
what are some alcohol-drug interactions with antidepressants?
- alcohol, increase sedation= little effect with alcohol SSRIs, venlafaxine, nortriptyline, clomipramine
- some additive sedation would be with, mirtazapine, mianserin, trazodone, amitriptyline, doxepin
- might lower the seizure threshold when using tricyclics
what are some NSAIDs-drug interactions with antidepressants?
- SSRI use roughly double the risk of upper GI bleeds
- warfarin, SSRIs significantly raise INR
- Tamoxifen, paroxrtine may increase the risk of recurrence of breast cancer
what are some smoking- drug interactions with antidepressants?
decrease duloxetine levels
what are some drug- drug interactions with antidepressants?
Clozapine levels increased- Fluvoxamine and SSRI’s Carbamazepine- ↓ Tricyclic’s Valproate- ↑ Tricyclic’s Cannabis Triptans
what is first and second line treatment for depression in children and adolescence?
fluoxetine with psychological therapies, with sertraline or citalopram as second
what is the only licensed drug for depression for 8-17y olds?
fluoxetine, only prescribed if they have been unresponsive to 4-6 sessions of psychological sessions
what is the only licensed drug for OCD for 8-17y olds?
sertraline
what drug shouldn’t be used in under 18s?
citalopram
what are some tips for using antidepressants in under 20s?
- need to positively exclude any possibility of bipolar depression e.g. family history
- counsel and be sure the family is aware of suicidal ideation
- start slow e.g. fluoxetine 10mg/d orodisposable or liquid
if someone has a possibility of bipolar depression under the age of 20 and need to start taking anti-depressants what should they put precsribed?
-look towards secondary care for consideration of other drugs like quetiapine and larazadone with a mood stabiliser
what to do for the use of anti-depressants in pregnancy?
-check latest’s guidance
-risk of depression may be higher than risk of antidepressant
-there is some links between SSRIs and incidences in autism
-paroxetine should be avoided
-
what is the guidance for antidepressant prescribing for the elderly?
-no ideal one
-SSRI better tolerated than TCA’s however increase risk of bleeds
-↑ risk of hyponatraemia, postural
hypotension, falls and haemorrhagic
stroke with SSRI’s
what is the guidance for antidepressant prescribing for cardiac disease?
-consults literature
-SSRI normally recommended
-mirtazapine maybe suitable alternative
-SSRI may protect against myocardial infraction
-sertraline drug of choice post MI
-CBT may be ineffective post MI, unless
depression present pre MI
WHAT ARE SOME OF THE CARDIOVASCUALAR effects of antidepressants?
• Antidepressants can increase QT intervalespecially SSRI’s and TCA’s
• Citalopram contraindicated in known
prolonged QT, medicines known to prolong
QTc, and should only be used with caution
with electrolyte disturbances and bradycardia
• Escitalopram is also contraindicated with QT
prolongation, drugs that may cause QT
prolongation, and should only be used with
caution in patients at risk of Torsades de
Pointes (TdP), recent MI, bradyarrhythmias,
hypokalaemia or hypomagnesaemia
Whatever you do, monitor fully
what are some guidance for prescribing renal impairment while using antidepressants?
Consult product literature
• No clear antidepressant preferred to another
• The greater the renal impairment, the greater the potential
for drug accumulation
• ADRs, such as confusion, postural hypotension and sedation
may be more common
• Serum creatinine levels may be normal in the elderly, despite
renal impairment
• Care is needed with drugs or active metabolites
predominantly cleared by the kidney, e.g. antidepressants
• Start doses low and go slow
• Care is needed with markedly anticholinergic drugs, which
may cause urinary retention and interfere with U&E measurements
what are some guidance for prescribing hepatic impairment while using antidepressants?
- consults literature
- greater degree of impairment=greater impairment of drug metabolism and greater risk of drug toxicity
- start low go slow and monitor LFTs regularly
- LFTs don’t necessarily correlate to metabolic impairment
- in serve liver disease avoid drugs causing marked sedation and/or constipation
- care needed with drugs with a high first-pass clearance
- paroxetine is used by some specialised liver units with few apparent problems
