Transcript Graham Scott ii mtg 8/9/98

Mental Health in Primary Care:
Management of Depression
Overview of MH in Primary Care
Recognition and Management of
Depression
Te Rau Hinengaro – the NZ
Mental Health Survey
 46.6% - Estimated lifetime risk for developing any
mental health disorder
 24.9% - Lifetime prevalence for the development
of any anxiety disorder
 20.2% - Lifetime prevalence for the development
of any mood disorder
 12.3% - Lifetime prevalence for the development
of any substance-use disorder
 20.7 % - Prevalence of mental disorder in past year
- Te Rau Hinengaro: The New Zealand Mental Health Survey (2006)
Te Rau Hinengaro – Mental
Health of Maori
 12 month rates
Maori – 29.5%
Other - 19.3%
 12 month mood disorder (depression, BPAD) rates
Maori – 11.6%
Other – 7.5%
 Corrected for age and socioeconomic factors
Gap reduced but still increased rates
 Higher rates of severe conditions among Maori
 Higher rates of suicidal thinking and behaviour
 Lower rates of access to health services
Te Rau Hinengaro – Mental
Health of Pacific Peoples
 12 month rates
Pacific – 24.4%
Other - 19.3%
NZ Born Pacific – 31.4%
Migrated after age 18 – 15.0%!
Higher rates in PI groups with longest history of “colonisation”!
 12 month mood disorder (depression, BPAD) rates
Pacific – 8.3%
Other – 7.5%
 Corrected for age and socioeconomic factors
Gap disappears, same overall rates BUT lower depression rates!!
 Sl. higher rates of severe conditions among Pacific
 Higher rates of suicidal thinking and behaviour
 Much lower rates of access to health services
Mental Health Treatment –
Unmet Need
 Only 38.9% of all 12 month cases of mental
disorders visited a health or non-health provider
 28.3% to a GP
 16.4% to a mental health specialist
 4.8% to a social services professional
 6.9% to a complementary or alternative medical
practitioner
 Of those who sought help, most visited a GP for
help with a mental disorder
 Rates of help-seeking/access to healthcare
lowest for PI, lower for Maori
- Te Rau Hinengaro: The New Zealand Mental Health Survey (2006)
How common are mental health problems –
the scale of the problem…all classes and cultures
Our children
1 in 5 under the
age of 15
Only 25% can
access care
50% bullied,
leading to:
•Depression
•Low selfesteem
•Suicide
1: 10 have
unrecognised
dyslexia,
dyspraxia
The workforce
Senior citizens
1 in 5 adults at any
time
Dementia effects
•5% over 65’s 1020% over 80
1: 10 have
depression
Suicide is the
greatest cause of
male deaths < 35 yrs
Work related stress
affects 25-30%,
? > 1 million work
days lost a year
1 in 6 over 65 suffer
from depression
Major factors:
•Social isolation
•Physical ill- health
30% of >65s in
med/surg beds have
dementia
All communities
Many spoken
languages in NZ;
many cultural beliefs
& mental health
issues
Over-representation
of Maori & Pacific
people in MH acute
inpatient & forensic
care
Causes of MH Problems – not only
a health issue
Victims of
domestic
violence
Elderly
isolated
men
Alcohol &
Drug misuse
Isolated
Women with
small
children
Employment
stress
•Bullying
•Harassment
Socio-economic
Disadvantage –
poverty, housing,
unemployment
Life cycle
time
•Divorce
•Retirement
•Redundancy
•Menopause
Long term
physically ill
Treatment of Common MH
Conditions in the Real World
Too often…
Presenting physical symptoms are the main focus
of assessment and intervention
When a MH condition is diagnosed people do
not access evidence-based interventions:
An SSRI is started at 20 mg and continued unchanged
despite partial or non-response
There is no practice-nurse phone support/follow-up
(despite compelling evidence of significant
effectiveness)
Very limited access to effective talking therapies
…though the PHO primary care programmes
have all slowly improved this situation.
Anxiety, Depression and Substance
Use disorders in General Practice
(12 months):
Total
Depression
18.1%
9.7%
Total Anxiety
22.2%
2.0%
8.0%
Total
Substance
11.3%
2.5%
6.7%
1.0%
5.8%
Patient Presentation to the GP
169
70
55
22
(43.9%)
(18.2%)
(14.3%)
(5.7%)
= physical acute illness.
= pain
= physical chronic condition.
= main reason psychological
Barriers to Care – Patient
Experience (Recent US/UK research)
 5 commonest presentations to Primary Care where
no obvious physical pathology:
 Headache, low back pain, lethargy, non-spec. GI and CVS
Sx
 Surveyed community prevalence of these
symptoms:
 On average significant Sx experienced every 3-4/7
 What determined whether these symptoms were
taken to the doctor/health centre??
 Main factor distinguishing those who went to Primary Care
was the presence of stress/distress/mental health condition
Barriers to Care: Patient
Perception - Disclosure
(MaGPIe data)
 Not wanting to talk about emotional problems
at all
 “They’re my private problems and I’m the only one that can
deal with it, I don’t see any relevant point in telling a doctor”
 Problem not bad enough to talk about to
anyone
 “Didn’t class them as medical, they weren’t the reason I went
to see doctor, they didn’t seem serious”
Barriers to Care: Patient
Perception - Role of the GP
(MaGPIe data)
 The GP is not the right person to talk to about
mental health problems
 “Only there for the flu. If you’re having emotional problems
you don’t take that to the doctor”
 “He’s there for the physical side of health”
 “I went to a counsellor instead”
 Worried about the GP's response
 “Thought he would presume I was a nutter and prescribe pills,
I didn’t think pills were the answer or he might refer me to a
psychiatrist and I didn’t want to be stereotyped”
 “Afraid of going back into hospital”
Co-Morbidity of Medical Illness
and Depression
Illness
% with Depression
Cancer
Heart Disease
Diabetes
Multi-infarct Dementia
Multiple Sclerosis
Parkinson’s Disease
Stroke
40 – 50%
18 – 26%
33%
27 – 60%
30 – 60%
40%
30 – 50%
Mental/Physical Health Link –
Example 1: Diabetes and Depression
 Patients with diabetes have double the population
incidence of depression – for reasons which are poorly
understood
 Depressed patients are three times more likely not to
comply with medical treatment
 Outcome of co-morbid diabetes/depression – poorer diet,
more hyperglycaemia, greater disability, higher
healthcare costs
 BUT… treatment of depression/anxiety in diabetic patients
results in dramatically improved mental and physical
health outcomes, lower secondary care costs – the
treatment pays for itself within 1 year
Mental/Physical Health Link –
Example 2: Depression and Heart Disease
 Depression predicts the incidence of heart disease
 Depressed patients have greater than three times the risk
of a cardiac event, in particular MI
 Depressed patients have reduced post-MI survival, poorer
adjustment, slower return to function, increased disability,
increased medical costs
 Treatment of co-morbid depression results in improved
mental and physical health outcomes, and lower
secondary care costs – the treatment pays for itself
Medically Unexplained Symptoms
20% of GP consultations
50% of outpatient consultations in specialist
care
More dissatisfied with GP care
Improve with psychological therapy ++,
medications +/-
Acute Care … money well spent ?
Medically unexplained symptoms
CBT is effective in :
• Irritable bowel syndrome
• Chronic fatigue
• Chronic Back pain
• Somatisation disorders
CBT is most effective:
Antidepressants are effective
in:
• Irritable bowel syndrome (a
bit)
• Chronic back pain (a bit)
• Chronic fatigue (not)
• Early in the disorder
CBT could be afforded in primary care by:
• Reducing acute outpatient clinic referrals
• Reducing one emergency admission a month would fund
0.75 of a psychologist
• Provide 4-6 sessions for 150 people a year
Patient Presentation to the GP
169(43.9%)
= physical acute illness
70
55
22
= pain
= physical chronic condition
= main reason psychological
cf
(18.2%)
(14.3%)
( 5.7%)
(38.2%)
(35.7%)
= DSM Disorder past 12 mths
Primary MH Care: The
Challenge
Most patients are experiencing physical
symptoms and wanting help with these
Stigma, attitudes re GP role/interest, and
beliefs re mental illness prevent ready
discussion of MH issues even when the
patient is aware of them
You only have 15 min to address these
issues, and agree a plan of action to
address MH issues…
Frequency of Consultation and
Identification of any Psychological Issue
Variable
Number of prior
consultations
Adjusted for age and sex
RR
95%CI
Never before
1
-
Once or twice
1.8
1.3 – 2.6
Three or four times
2.3
1.6 – 3.2
Five or more times
2.9
2.1 – 4.1
Questions and Discussion
Major Depressive Disorder
Diagnostic Criteria (DSM – IV)
1. Key Symptoms:

Depressed MOOD

Diminished INTEREST
2. Other Symptoms:







Appetite decrease (or increase) / weight loss (or gain)
Marked sleep disturbance (increase or decrease)
Psychomotor changes (agitation or retardation)
Fatigue or loss of energy
Feelings of worthlessness or guilt
Diminished concentration or indecisiveness
Recurrent thoughts of death or suicide
Either Key, and 4+ Other, for 2+weeks – MAJOR
DEPRESSION
Depression “Subtypes”
Depression is a syndromal description, within which several
discrete “subtypes” are identified. Those with important
treatment implications are:
 Melancholic – prominent early waking, diurnal variation,
psychomotor agitation/retardation, guilty thinking
Seems to respond better to Venlafaxine, TCA at antidepressant doses,
need medication before any psychological intervention
 Atypical – increased sleep, increased eating/weight, heightened
interpersonal sensitivity, weighed down feeling/”leaden limbs”
Poor response to most antidepressants; some response to Paroxetine,
better response to Venlafaxine, Phenelzine (MAOI) – best outcome
with CBT +/- antidepressants
 Psychotic – onset of psychotic symptoms during a depressive
episode, often mood congruent
Poor response to antidepressants alone – need antipsychotic as well
Differential Diagnosis of Anxiety
vs Depression
1. Screen for Depression and Anxiety Disorders
2. Given the common presence of symptoms of both,
what is the relative predominant cluster of
symptoms?
a. Depression – low mood, loss of interest/motivation,
anhedonia, early waking, low energy, hopelessness, etc.
VERSUS
b. Anxiety – anxious mood, initial insomnia, “nervous energy”,
etc.
3. What is the relative time course of symptoms of
depression vs symptoms of anxiety?
a. Are episodes of onset of depression, followed by onset of
anxiety symptoms, which resolve as depression recedes; OR
b. Has anxiety waxed and waned, with episodes of depression
superimposed (most often with worsening of anxiety)
Differential Diagnosis of Unipolar
vs Bipolar Depression
 Bipolar – COMMON cause of poor treatment
response, risk of inducing mania
 20% patients with depression have some form of
Bipolar Disorder – esp early onset, family history
 2-Question screen for Bipolar:
 Have you had periods where you can get by on less
sleep than usual?
 Have you had periods of doing things others may
think inappropriate eg, spending too much money
 Irritable mood common in both hypomania and
depression
 Outcome typically worse with antidepressants
Differential Diagnosis of Depression
vs Alcohol Abuse/Dependence
 Diagnosis of depression cannot be
accurately made in the face of significant
alcohol abuse/dependence
 Alcohol abuse/dependence can mimic
major depression
 In the presence of significant alcohol
abuse/dependence need to first treat for
this, then reassess re presence or not of
persisting depressive symptoms
Suicide Risk Screening
It looks from what you’ve told me that you’ve been feeling pretty bad
lately -



Do you see any future for yourself?
Do you feel you would be better off dead?
When you’re at your worst have you thought about ending your
life?




Have you thought about how to do it?
Do you want to act on this plan?
Have you got access to (planned means)?
Do you feel others would be better off without you?
* Escalating risk with each successive positive answer
Suicide Risk Factors
(Presence indicates increased risk)
 Severity of current depression and hopelessness
 Previous attempt(s)
 Alcohol/Drug abuse
 Social isolation
 Family History of suicide
 Medical co-morbidity
 Agitation
 Being an older male
 Recent significant loss(es)
Questions and Discussion
The Stress-Vulnerability
Model
 Multiple intersecting lines of research strongly
suggest that a person’s mental health at any
point is determined by the interaction of
vulnerability factors, and current stress levels
 Vulnerability (risk) factors –
 Biological – Genetic factors, brain insults/injury
 Psychological – adaptive/coping style
 Stress –
 Ambient stress – work stress, financial pressure etc.
 “Life events” – bereavement, divorce, change, etc.
The Stress-Performance
Relationship
PERFORMANCE
“A little stress is a good thing, too much is not!”
STRESS
Effects of Stress on the Body –
The “Sabre-Tooth Tiger” Problem
Body Change
Action or Short-Term Effect
Potential Long-Term Effect
Tense muscles
Quick Reaction
Headache; back, neck, shoulder and jaw
pain;fatigue
Restricted flow of blood to
skin
Blood diverted to other areas, minimises
blood loss in injury
Pallor, skin rashes; itching, dryness
Increased perspiration
Cools body
Loss of fluids; body odour
Minimises blood loss in
injury
Increased production of white blood Fights infection
cells
Increased heart rate
Increase flow of blood carrying oxygen
and nutrients
Blood clotting
Blood clots; stroke; heart attack
Immune system becomes unbalanced
High blood pressure irregular heart sounds;
rapid heart rate; damage to heart muscle
Digestion depressed
Provides more oxygen; eliminate carbon
dioxide
Blood diverted to other areas where needed
Nausea; indigestion; colitis, diarrhoea
Increase of acid in stomach
Irritates stomach lining
Ulcers
Decrease in saliva
Not needed for digestion
Dry mouth; indigestion; loss of voice
Liver releases extra sugar
More energy available
Diabetes
Increase of fatty acids and
cholesterol
More energy available
Cholesterol build-up in arteries; stroke; heart
attack
Pupils dilate
Increased visual perception
Impaired vision
Increased respiratory rate
Impaired breathing; hyperventilation
Awareness and Recognition:
Symptoms of Chronic Stress
STRESS AND
YOUR MIND
Constant worry
Racing mind
Illogic
Can’t concentrate
Easily distracted
Uncertainty
Forgetfulness
Poor memory
STRESS AND
YOUR BODY
Churning stomach Fatigue
Backache
Headaches
Palpitations
Diarrhoea
Chest tightness
STRESS AND
YOUR FEELINGS
Irritability
Anxiety
Anger
Low self-esteem
Impatience
Depression
Loneliness
STRESS AND
YOUR ACTIONS
Poor sleeping habits
Rapid speech
Reckless driving
Excessive drinking
Poor eating habits
Drug use
Excessive smoking
The Link Between Stress and
Mental Health/Illness
 From time to time, everyone faces things in life that cause
stress – we will all move up and down this continuum
 Sometimes, people’s normal coping skills are not enough to
deal with these stress events, leading to developing
symptoms
 In any one year, for 20% of the population, 35% of Primary
Care attenders, life stressors will be causing a mental health
or drug alcohol condition – or in our lifetimes this figure is
50%
Stress
Chronic Stress
Emotional Disorders
(Depression, anxiety,
alcohol and drug problems)
Increasing intensity of stressors
The Stress-Vulnerability Model:
Vulnerability:
•Biological
•Psychological
Vulnerability Threshold Research
Greater
Resilience
Unwell
Vulnerability
Threshold
Well
Greater
Vulnerability
Time
The Stress-Vulnerability Model:
Impact of Life Stress Research
Vulnerability:
•Biological
•Psychological
Life Events – one-off
stressful events/changes
Marital Separation
Unwell
Well
Job Loss
New Job
Ambient Stress – e.g. work
stress, marital problems, etc.
Time
Stress:
•Ambient life stress
•“Life Events”
The Stress-Vulnerability Model:
Medication Effect Research
Medication raises the vulnerability
threshold for as long as it is taken
Vulnerability:
•Biological
•Psychological
Unwell
Well
Time
The Stress-Vulnerability Model:
CBT Effect Research
CBT has a slower onset of action in raising the
threshold, but the effect is sustained over time
Vulnerability:
•Biological
•Psychological
Unwell
Well
Time
Questions and Discussion
Evidence-Based Treatments –
Overview
General Messages:
Expect full recovery, communicate this to patient,
treat vigorously, don’t accept non/poor-response
Non-specific therapeutic factors (rapport, strength
of relationship, the person feeling validated and
understood) make a significant contribution
towards good outcome, and are the largest effect
in psychotherapy outcome
Whatever interventions are made, persisting in
treatment, and maintaining hope and an
optimistic outlook, are the most critical factors
Evidence-Based Treatments –
Overview
 Supportive counseling and education re the
condition – what GPs and PNs do every day!
 Self-management focus – incl information/educn
 Lifestyle factors – Exercise, Sleep, Diet
 Activity Scheduling
 Brief problem solving
 Medications – around 50-60% response rate for any
1 medication (NB – placebo response rate 30%!)
 Phone follow-up/support – around 20% response
rate (as good as medication!)
 Cognitive Behaviour Therapy (also same response
rate as medication)
“The type of treatment matters less,
than ensuring it is done properly,
and followed up”
Ed Wagner
Effective Treatments for Depression
Mild Depression (PHQ-9 <15):




Support/advice
Exercise
Activity Scheduling
Problem Solving
Moderate/Severe Depression (PHQ-9 >15)
 The above plus…
 Antidepressant medication
 Cognitive Behavioural Therapy
Treatment of Depression –
Medication vs CBT
Source – RANZCP Guideline for Treatment of Major Depression (2002)
The Effectiveness of Treatments:
Uncomplicated Depression – Acute Treatment RCT’s Meta-Analysis
a.
b.
c.
CBT
SSRI
TCA
vs placebo
58.9% vs 28.2%
51.3% vs 29.1%
54.5% vs 34%
NNT – 3.27
NNT – 4.50
NNT – 4.86
Depression – Long-Term Treatment RCT’s Meta-Analysis
a.
b.
c.
CBT vs Antidepressant
CBT vs Placebo
Problem solving vs TCA
54.5% vs 35.5%
65.1% vs 37.0%
59.1% vs 55.2%
(ie. More or less equal)
NNT – 5.27
NNT – 3.56
NNT – 25.85
Getting maximum “bang for your
buck” – practice nurse phone
follow-up and support
 2-4 x 5 min phone calls over the first 2-4 weeks
following diagnosis/initiating treatment – most often
by practice nurse
 Provide support, encouragement, enquire re
medication adherence, address any questions,
reinforce key messages (incl time taken to respond
to antidepressants)
 Treatment effect is as strong as that of SSRI – is an
extremely cost-effective intervention
Self-Management
Key to improved outcomes in depression
as in all chronic conditions
Use of information resources, care plans –
negotiate agreed plan, follow-up re
progress with this
Start small/achievable and build from
there
Expect it will require fine tuning over time
Six Principles of
Self-Management
1.
2.
3.
4.
5.
6.
Activities that protect & promote health (Live a healthier
lifestyle)
Monitor signs/symptoms of illness and take appropriate
action to respond
Know and understand your health condition
Be actively involved in decision making
Manage the social / emotional and physical impact
Follow a care plan that is agreed with your health
professionals
(Battersby, 2005)
Key Components of SMS
1. Build patient’s selfefficacy (confidence)
2. Improve health
literacy
3. Use behaviour
change techniques
4. Share decision making
5. Collaborative,
planned care with
regular F/up
Share responsibility
and decision
making so patients
feel in control and
realise how
important their
actions are
Exercise in Depression
Evidence that in elderly (over 60) exercise
programme has same efficacy as
antidepressants
Must be vigorous exercise (for age/fitness)
Some evidence that balance of aerobic
and resistance exercise ideal
Integrate into Activity Scehduling
Activity Scheduling
Use of structured activity scheduling tool Key
aspect of “Behavioural Management”
See handout
Reverses cycle of low mood/despondency –
reduced activity – more time to dwell on
negative thoughts – lower mood
Important to include rating of sense of
pleasure and mastery from activity
Activity Scheduling Tool
DIARY OF DAILY ACTIVITIES
Please list all activities undertaken during the day. Rate each activity (using the scale below) for Sense of Pleasure (P) and Sense of Achievement (A).
SUNDAY
P
A
MONDAY
P
A
TUESDAY
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
RATING SCALE FOR SENSE OF PLEASURE (P) AND SENSE OF ACHIEVEMENT (A).
0
1
2
3
4
5
6
NONE
MILD
MODERATE
GREAT
P
A
WEDNESDAY
P
A
Brief Problem Solving
Proven effective in mild-mod depression
Focus is in mobilising the patient’s coping
and problem-solving capacity, to overcome
the issues that are causing stress/inducing
depression
Uses structured approach, increases sense
of mastery and reverses “helplessness –
hopelessness”
NDI Phase 2 – “The Journal” an
online self-management tool
Advertising campaign starts June 2010
Can be self-directed access OR via GP
Uses K-10 to monitor progress
People set goals re activity, exercise, diet
Get txt/email encouragement from “JK”
Includes a section on Problem Solving
Will be a great aide to managing
depression in primary care!
Cognitive Behaviour Therapy
(CBT)
 Structured, time-limited, ‘here and now’
 Specific skills for now and future
 Five components to problem (“Five-Part
Model”)
 Cognitive model
 Evidence
 Balanced thinking
CBT - 5-Part Model
Environment (Past & Present), Situation
Thoughts or
Cognitions
Behaviours,
Actions
Physiology,
Sensations
Feelings,
Emotions
CBT - 5-Part Model (contd)
COGNITIVE COMPONENT
EMOTIONAL
SITUATION
AUTOMATIC
THTS AND
IMAGES
LENS OR FILTER THROUGH
WHICH WE PRECEIVE OR
INTERPRET SITUATIONS
REACTION
BEHAVIOUR
PHYSIOLOGY
Classes of “Warpy Thoughts” –
Automatic, absolute, unbalanced
 Mind reading (“He thinks I’m a loser”)
 Fortune telling (“I won’t get the job even if I apply”)
 Catastrophising (“This plane is going to crash”)
 Unrealistic expectations of self (“Shoulds… musts…”)
 Personalising(“Everything is my fault”)
 Perfectionism (“no matter what I do it’s never good
enough”)
 Overgeneralising (“I always muck everything up”)
 Black-White thinking (“I didn’t win, I’m useless”)
 Looking on the dark side (“The world is a bad place”)
Pharmacotherapy of Typical
Depression
First line Rx in most instances is SSRI
Severe/Agitated Depression – Dual action Ads
(Venlafaxine, Mirtazapine, TCA) more effective
Non- or partial-treatment response – strong
evidence for both Nortriptyline and new dual
action ADs (Venlafaxine, Mirtazapine – NB: Voc.
Reg. GP can apply for SA)
 Nortriptyline in therapeutic doses – usually 75-100 mg
 Venlafaxine dose v. variable 75 mg to 450 mg
NB – monitor for incr BP at higher doses
 Mirtazapine dose 30-45 mg nocte
Treatment with SSRI
Initiate at 20 mg mane (if sedative effect
change to nocte)
Significant anxiety - ??initiate with low-dose
BZP or Quetiapine
Significant S/E – change to alternate SSRI
No or minimal response 2-3 weeks, increase
to 40 mg
Persisting poor response 4-6 weeks, change
to alternate SSRI progress as above
Pharmacotherapy of Other
Depression Subtypes
Melancholic Depression – TCA/Dual
action ADs more effective
Atypical Depression – Only Phenelzine has
strong evidence of effectiveness; some
evidence Paroxetine and Venlafaxine
Psychotic Depression – MUST treat with
antipsychotic (eg, low dose Risperidone)
plus antidepressant
Antidepressant Prescribing
Issues in Particular Populations:
Intention to Treat Meta-analyses of
Antidepressant trials
Children/Adolescents – Fluoxetine only AD with
any evidence of effectiveness; significant
concern re harms with ADs esp. other SSRI
Over 60 – trend-level data to suggest elderly do
better with dual action ADs – VF and TCA (BUT
TCA S/E issues)
Males – trend-level data to suggest men do
better on TCA
Antidepressant Prescribing
Issues in Pregnancy/Lactation:
Need to balance (uncertain) risks of “safe”
medications, with known risks to mother AND
child of untreated depression:
Nortriptyline, Fluoxetine considered “safe” during
pregancy, MAY cause withdrawal syndrome in
neonate
Paroxetine contraindicated 1st Trimester
Nortriptyline, Paroxetine only ADs with very low
levels in breast milk of treated mothers
NB – BZP relative contraindication (esp 1st
Trimester)
Managing Side Effects
The art of prescribing – matching
medication effect profile to symptoms
(e.g., sedating vs activating)
Managing sleep disturbance –
short term hypnosedative eg Zopiclone, OR
If also anxiety/agitation – low-dose Quetiapine
SSRI-related sleep disturbance –
 Short half-life SSRI OR change to alternate
agent
Sexual dysfunction – a tough one!
Monitoring and Follow-up
Need to closely monitor patients receiving
antidepressants for worsening and
suicidality especially at beginning of
treatment and with changes in dosage
Also need to instruct patients and families
to be alert for worsening or suicidal
thoughts and to immediately report such
symptoms
Use practice recall systems
Promoting Adherence
Shared decision making
Inquire into prior use of antidepressants
Explain that it may take 2 to 4 weeks for
therapeutic response, longer for full effect
Discuss most common side effects
Advise patients to continue medication
even if they feel better
Explain risk of stopping too soon
Phone follow-up/support – doubles
adherence!!! Is good practice nurse role.
Follow Up
Close follow up by telephone and or visits until
stable (phone support betw visits impt)
Depression scale (eg,PHQ-9) to assess progress
Titrate dose for total remission
Maintain effective dose for 6 to 12 months
(continuation phase)
Monitor for early signs of recurrence
Consider maintenance therapy if there have
been more than 2 episodes
Antidepressant Continuance
Relapse of depression is COMMON:
After one episode 50%, after 2 episodes 75%, after
3 episodes 90%
Risk reduced if patient accesses CBT
Usual advice re duration of antidepressant
treatment (from research re more severe
depression):
First episode – 6-12 mths
Second episode – 12-24 mths
Third + episode – 24 mths plus ??long-term Rx
Poorly Treatment Responsive
Depression
Defined as non- or partial-response to an
adequate dose of medication, for an
adequate duration, with good adherence
Effectively means 20-40 mg SSRI for 4-6
weeks (NB if no response at 20 mg after 2-3
weeks, trial increase to 40 mg)
Should be seen as a trigger for further
assessment re cause of poor response
Needs assertive response – greater duration of
depression, poorer chances of recovery
Poorly Treatment Responsive
Depression
Review diagnosis/presentation –
?adherence (common…) – ?why - address
?psychosocial issues/trigger – need CBT
?bipolar depression – need mood stabiliser
?atypical depression – need effective ADs/CBT
?comorbid A+D – need A+D Intervention
?other comorbidity - anxiety disorder, ADHD, etc
Intervention for these as appropriate
Poorly Treatment Responsive
Depression – STAR*D Trial
If above factors excluded, evidencebased treatment options for treatment
non-responsive depression are:
Substitute option 1 – Alternate SSRI*
Substitute option 2 - Venlafaxine or TCA
Augment option – Lithium, T3
Addition option – CBT
Continued non-response OR unsure Indication for Psychiatric Consultation
*Note that non-response to 1 SSRI is NOT highly predictive of non-response to a second,
so first-line strategy should be trial of a second SSRI.
When to Consult/Refer to DHB
MHS
Any case with serious suicide risk
Any case with psychotic symptoms or
possible evolving psychosis
Complex presentations with serious
impairment in function
Includes cases with significant comorbidities
Cases which fail to respond to treatment
Early referral important – duration of illness
inversely related to odds of full recovery
Other Resources for your
Patients
The PHO may have Community Health
Coordinator roles to assist with cultural &
social issues, linking to community
resources, sorting benefits/housing etc
Most PHOs now have access to funded
CBT/counselling
Think of the Primary Mental Health NGO’s
– Lifeline, James Family, Relationship
Services, Presbyterian Support etc.