depression dr. alan ng behavioural medicine. reference psychiatry in primary care editors:...

DepressionDr. Alan Ng

Behavioural Medicine

Reference

Psychiatry in Primary CareEditors: Goldbloom, DavineCAMH, Toronto 2011

Objectives

• Discuss the differential diagnosis of depression• How to screen for depression• Discuss the DSM V criteria for major depression episode• Discuss a strategy for psychopharmacology/use of antidepressants• What is reasonable to expect from a primary care physician in

managing depression?• When should you refer to a specialist?

What is the differential diagnosis of depression?

What is the differential diagnosis of depression?• Organic conditionsGenerally guided by history and examination

Screening bloodwork should normally be CBC (rule out anemia) and TSH unless otherwise indicated

• ETOH/substance abuse• medications

What is the differential diagnosis of depression?• Grief and major psychosocial stressors (adjustment disorder)• Bipolar disorder• Anxiety disorder• Personality disorder (especially cluster B)

How to make the diagnosis in less than five minutes

How to make the diagnosis in less than five minutesScreening questions (quick screen)

1. In the past month, have you lost interest or pleasure in things you normally like to do?

2. Have you felt sad, low, down, depressed or hopeless?

If answer ‘yes’ to either question, consider further exploration/assessment

What are risk factors for Major Depressive Episode (MDE)?

What are risk factors for Major Depressive Episode (MDE)?• Chronic insomnia or fatigue• Unexplained somatic symptoms• Chronic medical illness• Recent cardiovascular event (CVA,MI)• Recent trauma (psychological or physical)• Other psychiatric disorder• Family history of mood disorder• Extensive use of medical system (‘thick chart syndrome’)

What tools are available to make the diagnosis?

What tools are available to make the diagnosis?• SIGECAPS• PHQ-9• Mood Disorder Questionnaire

What is the DSM V criteria for major depressive episode?

What is the DSM V criteria for major depressive episode?A.• Five (or more) of the following symptoms have been present during

the same 2- week period and represent a change from previous functioning; • at least one of the symptoms is either (1) depressed mood or (2) loss

of interest or pleasure.

Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

What is the DSM V criteria for major depressive episode?• Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). • Significant weight loss when not dieting or weight gain (e.g., a change of more than 5 percent of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. • Insomnia or hypersomnia nearly every day.

DSM V criteria for MDE

• Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). • Fatigue or loss of energy nearly every day. • Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). • Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

DSM criteria for MDE

B. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

Source: DSM-V, American Psychiatric Association

Psychopharmacology

What is the goal of acute treatment?

Psychopharmacology

What is the goal of acute treatment?

• Full remission of symptoms• Return to baseline function• Can evaluate using PHQ-9, Beck, Hamilton rating scales

How do you decide how to choose an antidepressant?

How do you decide how to choose an antidepressant?• There is no one definite choice as it depends on individual variability

between efficacy and side effects

• Some evidence for increased efficacy with ecitalopram, mirtazepine and venlafaxine with severely depressed patients

• Some evidence for short-term tolerability with citalopram, escitalopram, moclobemide, sertraline

How do you decide how to choose an antidepressant?• Broad spectrum agent (for both anxiety and depression)

recommended due to high comorbidity for both disordersEg escitalopram, paroxetine, sertraline, venlafaxine(others may also be effective for anxiety disorders but studies have not been done)

• Bupropion, mirtazepine and moclobamide have fewer sexual side effects

First line antidepressants

• What would you choose as first line antidepressant?

First line antidepressants

• SSRI-selective serotonin reuptake inhibitors• SNRI-serotonin and norepinephrine reuptake inhibitors• Novel action• RIMA-reversible monoamine oxidase inhibitor

SSRI (CAMH 2011)

SSRI Usual daily dose (mg)

efficacy tolerability anxiety

citalopram 20-40 +

escitalopram 10-20 + + +

fluoxetine 20-40

fluvoxamine 100-200

paroxetine 20-40 +

sertraline 50-150 + + +

Efficacy-based upon meta-analyses and head to head trialsTolerability-based upon meta-analysesAnxiety-based on Canadian Anxiety Disorder Treatment Guidelines 2006

SNRI

SNRI Usual daily dose (mg)

efficacy tolerability anxiety

desvenlafaxine 50-100

duloxetine 60-120 +/-

Venlafaxine-XR 75-225 + +

SNRI=serotonin and norepinephrine reuptake inhibitor

Novel action

Novel action Usual daily dose (mg)

Efficacy Tolerability Anxiety

Bupropion-SR 150-300 +/-

mirtazepine 30-60 +/-

trazodone 200-400

RIMA

RIMA Usual daily dose (mg)

efficacy tolerability anxiety

moclobamide 450-600 +

RIMA=reversible monoamine oxidase inhbitor

What are the second line antidepressants?

Second line antidepressants

TCA

amitryptyline 100-250

clomipramine 100-250

desipramine 100-250

imipramine 100-250

nortryptyline 75-150

TCA-tricyclic antidepressants

What are the third line antidepressants?

Third line antidepressant

MAOI Usual daily dose (mg)

phenelzine 30-75

tranylcypromine 20-60

MAOI: Monaoamine oxidase inhibitor

Maintenance treatment

• What are the goals?• How long should you continue if patient has no risk factors?• How long should you continue if patient has risk factors?

Maintenance treatment

• What are the goals?• How long should you continue if patient has no risk factors?• How long should you continue if patient has risk factors?

Risk factors: chronic, recurrent, severe or difficult to treat episodes

Maintenance treatment

• What are the goals?• How long should you continue if patient has no risk factors?• How long should you continue if patient has risk factors?

• Prevention of relapse and recurrent• Without risk factors, 4-6 months• With risk factors, at least 2 years

Stopping medication

• How do you taper?• What are the common discontinuation symptoms?• Which medications are most likely and least likely to be associated

with discontinuation symptoms?

Stopping medication

• Gradually taper, at least one week between each dose reduction

FINISH mnemonic:• Flu-like symptoms• Insomnia• Nausea• Imbalance (dizziness)• Sensory disturbance (electric shocks)• Hyperarousal (agitation)

Stopping medication

• Discontinuation symptoms more likely with paroxetine, venlafaxine

• Less likely with fluoxetine, moclobemide

What do you do if there is no response to treatment?

What do you do if there is no response to treatment?• Check diagnosis (?bipolar, substance abuse)• Optimize dose, increase to max for several weeks, manage side-

effects• Add psychotherapy• Switch to another antidepressant• Augment with augmenting agent• Augment with atypical antipsychotic agent• Combine with antidepressant in a different class

Augmenting agents

Augmenting agents

• Triiodotyronine (T3) 25-50 ug/day

• Lithium 600-900 mg/day

Watch for increased side effect burden

Atypical antipsychotics

Atypical antipsychotics

• Olanzepine 2.5-10 mg daily

• Risperidone 0.5-3 mg daily

• Quetiapine 100-300 mg daily

Watch for increased side effect burden

Partial response to treatment

When there is partial response to treatment most clinicians would augment or combine so not to lose gains from the first antidepressant

(consensus, little evidence)

Is a washout period needed when switching between antidepressants?

Is a washout period needed when switching between antidepressants?• Only to and from MAOIs

How do you approach switching between antidepressants?

How do you approach switching between antidepressants?Two Approaches

1. Start second antidepressant at low dose while tapering off the first dose

Watch for side effect burden

2. If patient is sensitive to side effects, taper off the first antidepressant before starting the second

What general advice will you give to a patient when starting antidepressants?

What general advice will you give to a patient when starting antidepressants?• Antidepressants have a lag time of 2-3 weeks to response• Take medications daily• Side effects are usually mild and temporary• Continue on the medication for at least 6 months, otherwise the

symptoms may return• Do not stop antidepressants before checking with your doctor

Other treatments

• Psychotherapy (CBT, problem solving therapy, analytic therapy)• Self-management-patient education/involve patient in

plan/workbooks etc

• Exercise• Light therapy (SAD)• ECT

What is reasonable to expect from a primary care physician in treating depression?

What is reasonable to expect from a primary care physician in treating depression?• Diagnose and develop a treatment plan• Assess suicide risk• Monitor response and outcome using scales (PHQ-9)• Aim for complete remission of symptoms for acute and maintenance

treatment• Coach self-management and or use problem solving techniques• Manage medications-be familiar with at least two classes of

antidepressants and at least one augmentation strategy• Refer when necessary

When do you refer to a specialist?

When do you refer to a specialist?

• Complicating comorbidity (substance abuse, personality disorder, anxiety disorder)• Severe presentation (suicidality, psychosis,bipolar esp with mania)• Diagnostic clarification needed• Refractory to treatment (CBT, two or more medication trials)