Primary Mental Health Talk First, Prescribe Later

Size: px

Start display at page:

Download "Primary Mental Health Talk First, Prescribe Later"

Patience Osborne
5 years ago
Views:

1 Primary Mental Health Talk First, Prescribe Later PHARMAC Seminar, Mar 2017 David Codyre, primary care psychiatrist

Talk First, Prescribe Later Scenario 1 A 51 yo man presents with a complaint of profound fatigue, but screens positive for depression (PHQ-2), and presents as severely

2 Talk First, Prescribe Later Scenario 1 A 51 yo man presents with a complaint of profound fatigue, but screens positive for depression (PHQ-2), and presents as severely depressed, PHQ-9 score 25/27 seems to confirm this. What factors would tend to suggest you should talk first, prescribe later?? What factors would suggest you should prescribe now??

3 Talk First, Prescribe Later Scenario 1a History clarifies that onset is very recent the last 2 weeks There seem to be triggering events - a negative performance review by his boss, news of an impending restructure of the company, and a background of financial stress and marital discord You know him to be a man who is anxious and sensitive by nature He has a history of 2 past similar episodes precipitated by stress, he was prescribed an SSRI on both occasions and recovered over 4-6 weeks WHAT IS YOUR ADVICE TO HIM?? WHAT WILL YOU DO??

4 Talk First, Prescribe Later Scenario 1b History clarifies that he has had fluctuant depression for 5 years He has had a number of prior episodes of milder depression each time prescribed SSRI but with partial response only, resolving finally after 6-12 mths He had a period of therapy via the primary MH programme with no real benefit He has a strong family history of depression He is overweight, has over that time also developed type II diabetes You look back thru notes and see he has at times had raised CRP WHAT IS YOUR ADVICE TO HIM?? WHAT WILL YOU DO??

5 How does the evidence inform practise?? Depression a syndrome, multiple contributing aetiological factors genes, current life stress, PLUS early life adversity (ACE study) ALSO - probably several distinct depression subtypes reactive ( neurotic ); atypical ; and melancholic ( endogenous ) Most AD trials do not make distinctions re subtypes and find little evidence to suggest ADs are effective if they are is only in SEVERE depression (PHQ-9 > 20) BUT what of PHQ-9 25/27 for 2 weeks vs PHQ-9 19/27 for 2 years AD trials are also only for ONE antidepressant so drop-outs are a treatment failure In real life we can trial several options to find a tolerated effective option but what if this is just filling enough time that spontaneous remission occurs??

6 How does the evidence inform practise?? Guidelines thus fudge these issues recommend ADs for SEVERE depression only Some mood disorder research centres have focussed on validity of the subtypes and in particular have a body of research and clinical practice supporting the notion of a more melancholic/endogenous subtype which is not stress-induced, tends to worsen with age/older age of onset, assoc with inflammatory process, and differentially responds best to dual action ADs Expert Consensus ADs MOST indicated for the severer persistent form of depression which has melancholic features prominent EMW, guilt, anhedonia, psychomotor change, diurnal variation

7 STAR*D Trial Treating Depression in the Real World Applied evidence re depression treatment via an algorithm/decision tree, for people who had failed a trial of at least one medication (SSRI) goal of symptom remission 75% of patients who stuck with trial remitted! Step Treatment Remission % Response % 1 Citalopram 37% 48% 2 Switch Venlafaxine 25% 28% 2 Augment CBT 41% 30% 3 Switch Mirtazapine 12% 14% 3 Switch Nortriptyline 13% 17% 3 Augment Lithium 14% 16%

8 When do I prescribe?... recognising that I see a skewed subset of people with Depression CRITICAL role of Formulation how do we make sense of this? What is the relative weighting of emotional/psychological factors and stress, vs of more biological factors family hy, melancholic features BUT the more we had access to CBT, Mindfulness, etc the less I prescribed AND the more we had access to peer/cultural based support and could address psycho-social-cultural complexity the less I prescribed

9 What have I learnt along the way? ADs are a sometimes necessary but NEVER sufficient condition of recovery from Depression We ALL over-believe in their effectiveness and the more we believe they will work the better they do!!! The more we are able to have meaningful conversations with people about the circumstances in which they have found themselves struggling the more we open doors to a way forward And the more access we have to cultural and peer support, and then to effective talking therapies, the less we need to prescribe Ads BUT optimal prescribing of ADs is KEY to recover for some perhaps many people especially with more persistent and severe Depression

A new Anatomy of Melancholy: rethinking depression and resilience

A new Anatomy of Melancholy: rethinking depression and resilience Prof Declan McLoughlin Dept of Psychiatry & Trinity College Institute of Neuroscience Trinity College Dublin St Patrick s University Hospital