Depression Key slides

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Depression Key slides
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Identification and assessment NICE CG 90, Oct
2009

• Be alert to possible depression (particularly in
  those with a past history of depression or a
  chronic physical health problem with associated
  functional impairment) and consider asking people
  who may have depression
• During the last month, have you often been
  bothered by feeling down, depressed or hopeless?
• During the last month, have you often been
  bothered by little interest or pleasure in doing
  things?
• If yes to either follow-up (Whooley and
  Simon. New Engl J Med 2000343194250)

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Identification and assessment NICE CG 90, Oct
2009 NICE Full Guideline 90, Oct 2009

• Confirmation requires more detailed clinical
  assessment consider using a validated measure
  e.g. PHQ-9, HDRS, BDI
• Comprehensive assessment should not rely solely
  on symptom count. Consider
• Degree of impairment and/or disability
• Duration of episode
• Always ask a person with depression directly
  about suicidal ideas and intent.

PHQ Patient Health Questionnaire HDRS
Hamilton Depression Rating Scale BDI Beck
Depression Inventory
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Diagnosis of major depression by DSM-IVWilliams,
et al. JAMA 2002287116070 NICE CG 90, Oct
2009 Gruenberg AM, et al. 2005
http//media.wiley.com/product_data/excerpt/50/352
73078/3527307850.pdf

• Depressed mood
• Loss of interest or pleasure (anhedonia)
• Insomnia or hypoinsomnia
• Appetite or weight change
• Fatigue or loss of energy
• Increased/decreased psychomotor activity
• Guilt or feelings of worthlessness
• Suicidal ideation

X
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Management of depressionThe stepped care
modelNICE CG 90, Quick Reference Guide Oct 2009
Antidepressants for duration of illness at
least 6 months
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NICE Step 2 persistent subthreshold depressive
symptoms or mild to moderate depression
(1)NICE CG 90, Oct 2009

• Consider offering low intensity psychosocial
  interventions
• Individual guided self-help based on cognitive
  behavioural therapy (CBT) principles
• Computerised cognitive behavioural therapy (CCBT)
• A structured physical activity programme
• Choice of intervention should be guided by the
  patients preference
• Group CBT may be offered for those who decline
  low-intensity treatments
• Offer advice on sleep hygiene, if needed
• Monitor
• those judged to recover without a formal
  intervention
• those with subthreshold depressive symptoms who
  request an intervention.

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Using antidepressants for persistent subthreshold
depressive symptoms or mild to moderate
depressionNICE CG 90, Oct 2009

• Antidepressants
• Not recommended for the routine treatment of
  persistent subthreshold depressive symptoms or
  mild depression because the risk-benefit ratio is
  poor
• Consider them for people with
• Past history of moderate or severe depression
• Initial presentation of subthreshold depression
  that has been present for a long period
  (typically gt2 years)
• Subthreshold depressive symptoms or mild
  depression that persists after other
  interventions.

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NICE Step 3 persistent subthreshold depressive
symptoms or mild to moderate depression with
initial inadequate response or moderate and
severe depression NICE CG 90, Oct 2009

• Options
• Antidepressant (normally SSRI), or
• High intensity psychological intervention
• CBT (group or mindfulness-based)
• Interpersonal Therapy (IPT)
• Behavioural activation
• Behavioural couples therapy, or
• A combination of antidepressants and
  high-intensity psychological intervention (CBT or
  interpersonal therapy) if moderate or severe
  depression
• Choice depends on patients preference, duration
  of episode, trajectory of symptoms, previous
  illness course and treatment response, likelihood
  of adherence to treatment, likely side effects.

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Which non-drug treatments are recommended?NICE
CG 90, Oct 2009

• Low intensity psychosocial interventions
• Individual guided self-help based on cognitive
  behavioural therapy (CBT) principles
• Computerised cognitive behavioural therapy (CCBT)
• A structured physical activity programme
• High intensity psychological interventions
• CBT (group or mindfulness-based)
• Interpersonal Therapy (IPT)
• Behavioural activation
• Behavioural couples therapy
• Others
• Counselling
• Short-term psychodynamic psychotherapy
• Group-based peer support programmes is a
  low-intensity option for those with chronic
  physical health problems.

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Evidence on non-drug managementNICE Full
Guideline 90, Oct 2009Mead GE, et al. The
Cochrane Library 2009, Issue 4

• Low-intensity psychosocial interventions
• CCBT and guided self-help have some effect in
  reducing symptoms of depression vs. control (e.g.
  usual treatment, waitlist)
• The effect of physical activity is unclear, but
  it has other health benefits
• Recommended initial treatment for persistent
  subthreshold depressive symptoms or mild to
  moderate depression
• Higher-intensity psychological therapies (usually
  CBT or IPT)
• Evidence suggesting CBT has some benefits over
  antidepressants (e.g. depression score at 12
  months) and that adding CBT to antidepressants
  beneficial. Benefit of adding antidepressant to
  CBT less clear
• Limited evidence hasnt shown IPT, behavioural
  activation or couples therapy to be any better
  than CBT
• May be used instead of an antidepressant for
  persistent subthreshold depressive symptoms, and
  for mild to moderate depression with an
  inadequate response initially
• CBT or IPT should be used in combination with an
  antidepressant in moderate or severe depression.

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Which antidepressants should be used? NICE CG 90,
Oct 2009

• Should normally be a selective serotonin reuptake
  inhibitor (SSRI) in generic form because SSRIs
  are
• Equally effective as other antidepressants
• Have a favourable risk-benefit ratio
• Note that
• SSRIs are associated with an increased risk of
  bleeding (consider prescribing gastroprotective
  agent in older people who are taking NSAIDs)
• Higher risk of drug interactions with fluoxetine,
  fluvoxamine and paroxetine (see BNF)
• Higher incidence of discontinuation symptoms with
  paroxetine
• Consider toxicity in overdose for those at
  significant risk of suicide. Be aware
• Venlafaxine associated with greater risk of death
  from overdose
• Tricyclic antidepressants (except lofepramine)
  associated with greatest risk in overdose
• Discuss drug choice with patient
• Dosulepin should not be prescribed.

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NICE on choice of antidepressantsNICE Full
Guideline 90, Oct 2009 NICE CG 90, Oct 2009

• Antidepressants have largely equal efficacy and
  choice should be largely dependent on
• Side-effect profile
• Patient preference
• Previous experience of treatments
• Propensity to cause discontinuation symptoms
• Safety in overdose
• Interaction potential
• Normally choose SSRI in generic form SSRIs have
  favourable risk-benefit ratio
• Escitalopram wasnt judged to have any clinically
  important advantages over other antidepressants
• No advantage found for dual action
  antidepressants (e.g. duloxetine? and
  venlafaxine) over other drugs
• Increased risk of suicidal ideation/behaviour in
  younger patients taking antidepressants.

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Summary

• Diagnosis of depression in adults should be based
  on DSM-IV and assessment should not rely solely
  on symptom count
• In persistent subthreshold depressive symptoms
  and mild to moderate depression, non-drug
  treatments e.g. CBT form the mainstay of
  treatment, and antidepressants are not usually
  recommended initially because the risk benefit
  ratio is poor
• Antidepressants or psychological interventions or
  a combination should be considered in more severe
  or persistent disease. A combination is
  recommended for moderate or severe depression
• Antidepressants have largely equal efficacy and
  choice should be largely dependent on several
  factors including side-effect profile, patient
  preference, previous experience of treatments and
  interaction potential (normally a generic SSRI).