Future Proofing. Reducing the Risk of Recurrent Depression. Rob Shieff

Transcription

1 Future Proofing Reducing the Risk of Recurrent Depression Rob Shieff

2 Disclosures None

3 Depression a diagnostic look At least 2 weeks Low mood Anhedonia Sleep Appetite / Weight Fatigue Activity Self-worth Thoughts of death Thinking / Concentration / Decision making Distress / Impairment No other explanation

4 Sexual problems Pain and MUS D and A Self-worth Appetite Concentration Low mood Anhedonia Insomnia Suicide Anger Relationship problems Fatigue Activity Vocational Problems Anxiety

5 The 5 Rs Response, Remission, Recovery, Relapse and Recurrence Presentation Remission Recovery Normal S E V E R I T Y Symptoms Syndrome Response Relapse Chronicity Partial Remission Recurrence 16 weeks 12 months 12 months Acute Continuation Maintenance TREATMENT PHASE

6 The Size of the Problem New Zealand : Life-time prevalence = 16% World wide : Prevalence varies widely USA : 17 % Japan : 3 % Gender : Female : Male = 2 : 1

7 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

8 What does this mean? Managing Depression is a Two Target Process Treat the current episode Make sure that this is the last episode

9 The first step in preventing recurrence Treat the current episode to REMISSION Symptoms Gone Functioning Normal or Very few / Very mild

10 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

11 Treatments Securing won t work Remission if they re not used 1. Support side-effects We can increase adherence by offering : Make it a shared goal 2. Information Treat comprehensively benefit Realistically optimistic probable benefit and time-frame Treat aggressively and tenaciously Accurate and specific side-effects : type and management Target adherence Weeks

12 Game Breaking Side - effects Weight gain Sexual dysfunction

13 Fighting against weight gain Problems 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 Exercise 3. Hungrier / Lose the feeling of fullness 5 3 meals / smaller portions 5 6 small meals / protein Topiramate 4. Carbohydrate craving Low GI carbs Limit carbs after lunch Eat your breakfast yourself, share your lunch with your friends and give your dinner to your enemies. 5. Metabolic shift Metformin Garcinia cambogia

14 Sexual Dysfunction Interest / Arousal / Orgasm You won t find out if you don t ask Symptoms of Depression Side effects of Medication

15 Offenders SSRIs / Venlafaxine > TCAs > Others Paroxetine > The Rest

16 Strategies Wait Wait Wait Reduce dose ( beware relapse ) Drug holiday ( beware withdrawal ) Add : Sildenafil ( Men and Women ) Bupropion Mirtazapine Ginkgo biloba Switch : Bupropion Mirtazapine Duloxetine

17 Preventing Recurrence

18 Comprehensive Care MEDICATION PSYCHOLOGY LIFE - STYLE

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20 Managing Medication Into the Future How much? Carry on with whatever it took to get fully better How long? At least 6-9 months following recovery

21 Mood 20% Time (months) 35% 55%

22 The Case for Longer Term Treatment Recurrent Depressions are likely to recur Recurrence rates are higher with medication alone Psychological / Life-style factors are protective Extend treatment if : Multiply recurrent / Severe RESILIENC Unable or unwilling to add other strategies to pills New evidence may support life-long treatment in all cases E Depressions occur while on medication

23 Non-medication Approaches

24 Knowledge

25 Complementary Medicine St. John s Wort ( Hypericum perforatum ) Omega 3 Fatty Acids S Adenosylmethionine ( SAMe) Inositol Resveratrol Magnesium Vitamin D

26 Manage Stress

27 Drugs and Alcohol Alcohol Ideally : zero Realistically : 2 3 Alcohol Free Days each week 3 4 standard units on drinking days Ideally : zero Drugs Realistically : depending on the drug - as low as negotiable 1.6 units 33 units 7 units Ideally : zero Caffeine 1.3 units

28 Life - style Activity Scheduling Structure C B T Balance

29 Depression : The Lost Disorder Loss of : Interest Energy Joy Confidence Enthusiasm Motivation Concentration Will Purpose INACTIVITY WITHDRAWL

30 The Worse I Feel The Less I Do

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32 Consequences When We are The we what do less less, we we do we do the tend If more to we lose stop empty structure doing, space we and we loose balance create worth in in our / our value lives If we stop doing the things that make us feel happy, we tend to stop feeling happy 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

33 The Process Take one day at a time Break the day into hourly blocks Match activities to times Model together, apply at home Best done just before bed Review today ~ plan tomorrow Brighter mood Ready for the morning Tomorrow

34 Sleeping Eating WORK Achievement Pleasant Activities Activities The Crucial The Basics Extras and / or THINGS I LIKE I NEED TO TO DO DO Things you enjoy once they re done Things you enjoy while you re doing them Try to Try do to 2 do 3 2 each 3 day each day Harder to find : Jobs or tasks from a To Do List Routine What did you use to like to do? Add in appointments Afternoon exercise What do your friends Earlyishlike dinner doing? To Do Supper List What have you Recurring Hot always Things shower wanted : / bath to do? Plan for: Stroll around Cooking a Herbal big book remedies shop Dark and quiet Exercise Cleaning Bed ( ~ for 30 sleep - 40 only min ) Washing Shopping One Off Things : Sort the IRD Relaxation ( ~ min ) Prune the roses Sleep Hygiene In bits Tomorrow Wake up Meditation Breakfast Load of Washing Coffee with Kate Lunch Walk Go to the doctor Reading Cooking Dinner Do the Dishes Watch DVD with Paul Go to Bed

35 Manage Physical Health and Pain

36 Crucial Basic Psychological Strategies

37 A Stitch in Time Early Warning Signs Action Planning

38 Early Warning Signs Onset of Depression is often a slippery slope Future episodes tend to mimic past episodes The earlier you spot it, the easier it is to stop 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 shift of sleeping pattern irritability sense of humour goes singing in the shower stops misses gym sessions

39 Action Planning If you know what to look out for Let other people know Look for precipitating stress and deal with it You keep your eyes 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

40 A common problem A solution 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

41 A couple of thoughts about thoughts We all have negative thoughts from time to time Is there a difference between : I I made a mess of that I made a mess of that I don t know why I bother I never do anything right No wonder noone likes me

42 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

43 Unless we re careful, we tend to think our thoughts are facts Viagra 4U FW: Registra American Exp Nigerian gold Term 2 : ݝݝ ݗݡۻݭݩf لكككىففi Cateye PC Melbourne flight Re : Medication

44 Mindful inattention Sorting Thoughts Junk Thoughts Take action Helpful Thoughts to think about Review and - if need be - take action Un-helpful

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46 that s all from me

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