Transcript Recurrence

Future Proofing
Reducing the Risk of Recurrent Depression
Rob Shieff
Disclosures
None
The 5 Rs
Response, Remission, Recovery, Relapse and Recurrence
Remission
Presentation
Recovery
Normal
S
E
V
E
R
I
T
Y
Partial
Remission
Symptoms
Response
Recurrence
Relapse
Syndrome
Chronicity
16 weeks
12 months
Acute
Continuation
TREATMENT PHASE
Maintenance
The Size of the Problem
New Zealand : Life-time prevalence = 16%
Risk for Depression Accumulates
Lifetime risk for First Episode = 16%
Risk for recurrence after 1 episode = 50%
Risk for recurrence after 2 episodes = 65%
Risk for recurrence after 3 episodes = 70%
Intensity of Recurrent Episodes Increases
What does this mean ?
Managing Depression is a Two Target Process
Treat the
current
episode
Make sure
that this is
the last
episode
The first step in preventing recurrence
Treat the current episode to REMISSION
Symptoms
Functioning
If something’s worth doing, it’s worth doing properly
Gone
or
Very few / Very mild
Normal
Why is Remission so important?
 Partial response without remission is associated with :

Impaired Quality of Life
• Higher
Risk of Recurrence
 lower work productivity / worse social functioning



intensification of other psychiatric / physical health problems
greater health care use
higher suicide rate
Remission
TreatmentsSecuring
won’t work
if they’re not used
We can increase adherence by offering :
• Make it a shared goal
benefit
1.
2.
Support
side-effects
Information•
Treat comprehensively
Realistically optimistic – probable benefit and time-frame
• Treat aggressively and tenaciously
Accurate and specific – side-effects : type and management
• Target adherence
Weeks
Game Breaking Side - effects

Weight gain

Sexual dysfunction
Fighting
gain
Problems against weight
Solutions
1. Dry mouth
Calories in drinks
Water or low calorie drinks
Patients can’t put on 10kg if you don’t let them put on 5kg
2. Calmer / less agitated
Burn fewer calories
5
3. Hungrier / Lose the feeling of fullness
4. Carbohydrate craving
5. Metabolic
shift breakfast
Eat your
Exercise
3 meals / smaller portions
5 – 6 small meals / protein
Topiramate
Low GI carbs
Limit carbs after lunch
Metformin
yourself , share your lunch
with your
cambogia
friends and give your dinner to yourGarcinia
enemies.
Sexual Dysfunction
Interest / Arousal / Orgasm
You won’t find out if you don’t ask
Symptoms
of
Depression
Side – effects
of Medication
Offenders
SSRIs / Venlafaxine
>
TCAs
>
Paroxetine > The Rest
Others
Strategies
•
Wait Wait Wait
•
•
Reduce dose ( beware relapse )
Drug holiday ( beware withdrawal )
•
Add :
Sildenafil / Tadalafil
Bupropion
Mirtazapine
Ginkgo biloba
•
Switch : Bupropion
Mirtazapine
Duloxetine
( Men and Women )
Preventing Recurrence
Comprehensive Care
MEDICATION
PSYCHOLOGY
LIFE - STYLE
Managing Medication Into the Future

How much?
What gets you well keeps you well
Carry on with whatever it took to get fully better

How long?
At least 12 months following recovery
Mood
20%
Time
(months)
35%
55%
The Case for Longer Term Treatment

Psychological / Life-style factors are protective

Extend treatment if :




Multiply recurrent / Severe
Unable or unwilling to add other strategies to pills
New evidence may support life-long treatment in all cases
RESILIENC
E
Depressions occur while on medication
Hot off the press
Continue pills

Optimal
Medication
strategy to minimise depressive recurrence
Stop pills

Multi-centre
Large numbers
Carefully set up / delivered / analysed

Un-replicated


Medication
+
CBT
Continue pills
Stop pills
Acute Treatment / Continuation
Maintenance
100%
S
U
S
T
A
I
N
E
D
73%
Continue Medication
Medication
+
CBT
R
E
C
O
V
E
R
Y
63%
37%
Medication
29%
Discontinue
Medication
17%
16%
0%
6
12
18
24
30
36
42
48
Months
54
60
66
72
78
Non-medication Approaches
Knowledge
Complementary Medicine
• St. John’s Wort ( Hypericum perforatum )
• Omega 3 Fatty Acids
• S – Adenosylmethionine ( SAMe)
• Inositol
• Resveratrol
• Magnesium
• Vitamin D
Manage Stress
Drugs and Alcohol
Alcohol
Ideally
: zero
Realistically :
2 – 3 Alcohol Free Days each week
3 – 4 standard units on drinking days
Drugs
Ideally : zero
Realistically : depending on the drug - as low as negotiable
Caffeine
Ideally : zero
Life - style
Activity Scheduling
CBT
Structure
Balance
Depression : The Lost Disorder
Loss of :









Interest
Energy
Joy
Confidence
Hope
Motivation
Concentration
Will
Purpose
INACTIVITY
WITHDRAWL
The Worse I
Feel
The Less I
Do
Consequences
If we
doing
the
things
thatIfmore
make
us structure
feel
happy,
we
tend
to stop
feeling
happy
When
we
do
less,
we
tend
to
and
balance
lives
Westop
are
The
what
less
we
we
do
do……
the
welose
stop
empty
doing,
space
we
we
loose
create
worth
ininour
/our
value
lives
Antidepressants are anti-sad pills, they are not happy pills
Happiness is a by-product of what we do
“ I’ve got to stop these pills ….. they’re making me feel flat ”
The Process
Tomorrow
6-7
7-8
8-9

Take one day at a time
9-10

Break the day into hourly blocks
11-12

Match activities to times
1-2

Model together, apply at home
3-4

Best done just before bed
5-6



Review today ~ plan tomorrow
Brighter mood
Ready for the morning
10-11
12-1
2-3
4-5
6-7
7-8
8-9
9-10
10-11
Tomorrow
“Achievement”
“Pleasant” Activities
Activities
The Crucial
The Basics
Extras
THINGS
TOTO
DODO
THINGSI LIKE
I NEED

•
•
Things you enjoy once they’re done
Things you enjoy while you’re doing them
Sleeping
6-7
Wake up
7-8
Meditation
8-9
Breakfast
9-10
Load of Washing
10-11
Coffee with Kate
Try• toTry
do to
2 –do3 2each
– 3 day
each day
11-12
WORK
 • Eating
12-1
Lunch
1-2
Walk
Sleep Hygiene
Harder to find :
• Jobs or tasks from a “ To Do” List
Routine
“ What did you use to like to do ? ”
Afternoon exercise
 Add in appointments
Earlyishlike
dinner
“ What do your friends
doing ? ”
To DoSupper
List
“ What have youHot
always
wanted
to do ? ”
shower
Recurring Things
: / bath
 Plan for:
remedies
Stroll• around
a Herbal
big book
shop
Cooking
Dark and quiet
CleaningBed
 •Exercise
( ~for30
40
sleep
onlymin )
In -bits
• Washing
2-3
3-4
Go to the doctor
4-5
Reading
5-6
Cooking
6-7
Dinner
7-8
Do the Dishes
One – Off Things :
8-9
Watch DVD with Paul
• Sort the IRD
9-10
• Shopping
and / or
 •Relaxation
( ~ 20
Prune the roses
- 30 min )
10-11
Go to Bed
Manage Physical Health and Pain
Crucial Basic Psychological Strategies
A Stitch in Time


Early Warning Signs
Action Planning
Early Warning Signs
• shift of sleeping pattern


Onset of Depression is often a slippery
slope
• irritability
Future episodes tend to mimic past
episodes
• sense
of humour goes
• singing in the shower stops


The earlier you spot it, the easier •itmisses
is to gym
stopsessions
it
Symptom profiles tend to be idiosyncratic



Help the patient identify their early signs of a slip
Remember that early changes are often more obvious to
someone else
Make a list and use it as a reference
Action Planning
If you know what to look out for
• Let other people know
Lookyour
for eyes
precipitating
stress and deal with it
You•keep
open
• Keep active and busy
• Fight negative thoughts
You take action early
• Be prepared to review medication options
You are more likely to stay well
A solution
A common problem
with most therapies
A Therapy Wind-shift
Mindfulness Meditation
anxiety
Acceptance and Commitment Therapy
(peace
ACT)
misery
The more you think about your thoughts and feelings, the worse you feel
A couple of thoughts about thoughts
We all have negative thoughts from time to time
Is there a difference between :
II made
made aa mess
mess of
of that
that
I made a mess of that
I don’t know why I
bother
I never do anything
right
No wonder noone likes me
It’s not our thoughts and feelings that get us into trouble
It’s the way we think and feel about our thoughts and feelings
that does the damage
Unless we’re careful, we tend to think our thoughts are facts
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Re : Medication
Sorting Thoughts
Mindful inattention
Junk Thoughts
Take action
Helpful
Thoughts to think about
Review and - if need be - take action
Un-helpful
… that’s all from me