Nick Venters Consultant Psychiatrist.

    1 in 15 W0men. 1 in 30 men. (Metzer 1994) You will each see 60 to 100 new cases a year in primary care 30000 workers in Britain believe they suffer from work-related stress, anxiety or depression (HSE 1995) Costs the UK economy £3.4 Billion

Edinburgh 5.9% London 7% USA 5.2% Uslun and Sartorius 1993 WPA/PTD Educational Programme on Depressive Disorders Athens 7.4% Canberra 4.8%

     400BC Hippocrates “The Nature of Man” Mania=Yellow Bile, Melancholia= Black bile 100-400AD “Acedia” (deadly sin= dejection, disgust, laziness) 500AD Pope Gregory the Great defined Acedia as illness and not sin- 1 st mental illness.

Robert Burton 1577-1640 1 st Detailed study “Anatomy of Melancholy” C19 th to C20 th major illness” Shift to “Depression” as more Physiological... “ a rut in the ground an economic term...a wimp of a word for such a Styron 1991

Prince et al. Lancet 2007 Sept 8;370: 859-77

  Childhood Relative Risk  Mum divorced 1.32

 Mum remarried 1.93

 Remarried with further conflict 3.42

 Childhood Sexual Abuse >4 Loss of Parent Before age 11 taught in the past. Actually most kids cope with bereavement, but change in circumstances may have an effect.

 However having one good relationship in childhood and high IQ is protective against adversity

  Twice as common in the lowest social class. More likely to be persistent Cause or Effect?

Lorant et al. Am Journal of Epidemiology 2003

 6 fold increase within 6 months of life event ▪ “Top 5” Death of Spouse, Divorce, Separation, prison, death of family member------- ALL ABOUT LOSS! ▪ 42% of recently bereaved spouses would fit criteria for depression at 12 months (Clayton and Darvish 1979)    Not everyone is as susceptible Chronic social problems matter too!

Social Support is an important protective factor.

      Stroke: 20% (closer to frontal lobe-less depressed in left sided lesions!) Parkinson's: 50% (more than other similarly disabling conditions) Epilepsy:6-30% (10 times higher suicide rate than general population) Persistent Pain: 30-54% More strongly associated with Central Pain (Fybromyalgia and IBS) than Peripheral Pain (R.A. or cartilage damage)). Coronary Heart Disease 27% (Increased mortality post MI) Cushing's but not thyroid disease.

           Depressed mood: different from sadness because of

pervasiveness, intensity, duration

 May be concealed Anxiety Nothing Subjective there then! Agitation Irritability Anhedonia: the feeling of having lost feelings Anergia Retardation: 50% feel movements are slowed Impaired concentration Loss of interest Disturbed sleep Loss of libido

   Are you depressed?

Do you feel down or hopeless?

Have you lost interest in things?

If the answer is yes then  Review mental state.  Look for social functional and relationship problems PHQ 9  94% Sensitive 61% Specificity Spitzer et al

     Past history of mood elevation Chronic physical health problems Previous response to treatment Relationship problems Social isolation and living conditions  Think about risk from the outset.

 Agitation, Anxiety Suicidal ideation.

      Guilt and self reproach affects 75% of sufferers, worthlessness, responsible for their depression.

Disturbed judgement Hypochondriacal ideas are often prominent Future is hopeless, pessimism is central.

Sense of being (correctly) blamed...can extend into persecutory delusions. Mood congruent OCD symptoms in 20-30%

   Mild: difficulty in continuing with ordinary social and work tasks At least 2 weeks of low mood with some Moderate : More symptoms and Considerable difficulty continuing with social, work and domestic activities. (Usually with some somatic symptoms).

Severe:  Considerable distress agitation or retardation. Guilt and very low self esteem to be expected. Most somatic symptoms seen. Somatic symptoms: anhedonia, anergia, reduced reactivity, early morning wakening, psychomotor retardation, agitation, reduced appetite, weight loss, reduced libido.

     If also anxiety, treat the depression first.

Mind: Mindcasts podcasts.

Sleep hygiene: Royal College of Psychiatrists Northumberland Mood juice Active monitoring for mild/sub-threshold: Review in 2 weeks. Provide information. Contact the patient if they DNA.

Self help: Mind over Mood or Overcoming Depression.

    Guided self help on CBT principals. Could be computerised CBT Group or even computer based CBT Structured activity programme Peer support.

Sad Lonely Upset Emotions Thoughts Nobody Likes Me Behaviours Stay at home Chest Tightness Nausea Bodily Sensations

   Past history of moderate or severe depression Sub-threshold symptoms for 2 years.

Severe Depression (alongside CBT)

   Triple risk of GI bleeding especially alongside NSAIDs Citalopram and Sertraline have fewer interactions.

Paroxetine has the worst discontinuation symptoms.

Better!

Comparative efficacy and acceptability of 12 new -generation antidepressants. Andrea Cipriani. Lancet 2009; 373

   There is no role for Dosulipin(Dotheipin). Don’t use it!

Combining TCA and SSRI can cause an unpredictable increase in TCA plasma concentration. As much as four times!

Tricyclics have not been shown to improve sleep. Nor for that matter has Mirtazapine.  Leave a 4-7 day washout period when stopping Fluoxetine and starting TCA. The other SSRIs can be cautiously cross tapered.

 Clomipramine worth considering if symptoms of OCD and Imipramine where panic symptoms are evident. both start 25mg and slowly increase to 150mg per day.

  Mirtazapine 15-45mg. Sedating-paradoxically more so at 15 than 45mg. Good as alternative to SSRI. In secondary care we sometime combine with SSRI St Johns Wort: Hypericum perforatum ▪ May be effective in mild/moderate depression. Unclear mechanism of action (MAO, NA, 5HT?) ▪ Unlicenced. Can interact with other medication including OCP, digoxin, gliclazide, statins and Warfarin ▪ Increased bleeding, hypersensitivity reactions, can precipitate mania ▪ Active component can vary 50 fold between preparations

     Are they taking the tablets.

Switch to another AD. First off: another SSRI or Mirtazapine (NICE). I would include Venlafaxine in this list (up to 225mg). You can quickly switch from SSRI to SSRI (not so when other antidepressants are involved) You could consider Tricyclic as an alternative Imipramine (good for anxiety), Lofepramine- less toxic in overdose. Trazadone- Sedating. More psychology: This time 16-20 sessions over 3-4 months (or more if needed to achieve remission)- High intensity IAPT NICE If that doesn’t work, you might start to think whether CMHT referral is warranted.

    More CBT based work, IPT, Psychodynamic Psychotherapy, Combination antidepressants, antipsychotics, Lithium, other mood stabilisers, ECT.

Work on psychosocial factors: Housing, benefits etc.

Manage Risks.



First episode: 6-9 months after full remission But 50-85% of patients will go on to have a second episode and 80-90% of these will go on to have a third. Forshall et al Psych Bullitin 1999 Treatment with Antidepressant reduces odds of relapse by 65% Glue p et al ANZJPsych 2010



Second episode : Continue for at least 2 years

       A pattern of depression seen for over 2000 years.

10% of patients with major mood disorder will have a seasonal pattern.

Popularised as SAD: depressive symptoms with some differences: hypersomnia, increased appetite with carbohydrate craving Mostly mild to moderate severity USA: Jan-Feb, Europe: Nov-Dec Prevalence of up to 10% USA (3% Europe) esp northern latitudes 2/3 will report improvement after 5 years.

     10,000 lux for 30 mins Early morning use more effective but can lead to jumpiness, headaches and nausea Dawn Simulators can be an alternative Clearly continue until Spring Antidepressants may also help

   Depression Alliance: www.depressionalliance.org

Depression UK http://www.depressionuk.org/index.shtml

Samaritans 24-hour helpline: 08457 90 90 90 email: [email protected]

web: samaritans.org

Freepost RSRB-KKBY-CYJK, Chris PO Box 90 90 Stirling FK8 2SA