PREPARATION FOR Effective use of antidepressants EDUCATIONAL VISITING PROGRAM SELF-ASSESSMENT QUESTIONS

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1 PREPARATION FOR EDUCATIONAL VISITING PROGRAM SELF-ASSESSMENT QUESTIONS General information about diagnosis and management of depression Major depression is diagnosed on the basis of DSM-IV criteria. These criteria include a number of symptoms, at least one of which must be either depressed mood or loss of interest/pleasure In addition, list four other symptoms that may be used to diagnose major depression according to the DSM-IV classification Significant weight loss or weight gain, or an increase or decrease in appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness, or excessive or inappropriate guilt Diminished ability to think or concentrate, or indecisiveness Recurrent thoughts of death or suicidal ideation/attempt What other factors does DSM-IV consider when assessing the severity of major depression? Number and intensity of symptoms Degree of functional impairment (consider social, occupational or other important areas of functioning) Risk of suicide (including degree of suicidal thinking or planning) How is adjustment disorder with depressed mood distinguished from major depression? In adjustment disorder with depressed mood there are fewer symptoms of depression (2-4 DSM-IV symptoms) and an obvious stressor (eg marital breakdown, financial problems etc); and, the person s depressive symptoms are considered a response to the event. Note that episodes of major depression can be initiated by such stressors List the three treatment phases of major depression. What is the aim of therapy for each phase? I. Acute treatment phase reduce symptoms and improve functioning II. Continuation phase preserve remission and prevent relapse III. Maintenance phase prevent recurrence Page 1 of 8

2 What are the two main factors contributing to inappropriate treatment of depression (according to Therapeutic Guidelines: Psychotropic)? I. under-treatment of patients with major depression II. inappropriate treatment of patients who are not clearly depressed Key Message Use non-drug therapy first in mild depression where it is unclear if antidepressants are better than placebo. the evidence that antidepressants are better than placebo is in moderate to severe depression Are the following statements true or false according to currently available evidence? Depression specific psychological therapy is a useful adjunct to antidepressants in severe depression - True Depression specific psychological therapy and antidepressants have similar efficacy in moderate depression - True In mild depression, antidepressants are first line - False All psychological therapies have similar efficacy in the treatment of depression (e.g. supportive counselling, cognitive behavioural therapy, psychodynamic psychotherapy) - False List six non-drug treatment options for mild depression I. Jnformation and education about depression II. Supportive counselling III. Brief CBT or IPT (6-8 sessions) IV. Problem solving therapy V. Guided self-help books based on CBT principles VI. Computer based CBT VII. Exercise (2-3 structured, supervised sessions per week) Which psychological treatments have the best efficacy for moderate depression? I. CBT II. IPT Summarize the evidence supporting the use of non-drug therapy The following non-drug strategies have evidence supporting their use in mild depression or minor 1 depression: brief cognitive behavioural therapy (CBT) or interpersonal therapy (IPT) (6 8 sessions) problem-solving therapy physical exercise (structured, supervised 2 3 sessions per week) guided self-help books based on CBT principles computer-based CBT (e.g. supportive counselling by GP or other health professional some depressive symptoms but not enough for a diagnosis of major depression Page 2 of 8

3 Non-drug therapies may also be considered as adjuncts to antidepressants in moderate depression. The evidence for efficacy of antidepressants is in moderate to severe major depression. 1-3 In patients with severe depression, psychological treatments alone are insufficient and antidepressants may be needed to improve functioning to a level where patients can engage in psychological therapy. CBT or IPT is indicated for relapse prevention: when residual symptoms persist after adequate duration of antidepressants as booster sessions for patients who have responded to psychological therapy Briefly discuss limitations of the data supporting the use of antidepressants The limitations of the data supporting the use of antidepressants are. The evidence does not apply to mild or minor depression At least 80% of the efficacy data for antidepressants is from specialist psychiatric care and may not be relevant to primary care. 4 In trials submitted to the US Food and Drug Administration (FDA), 70 90% of the symptom improvement seen with newer antidepressants also occurred with placebo. 5 In many trials, there was no significant difference between placebo and antidepressants in symptomatic improvement. 6 Because such negative trials are seldom published, effectiveness can be overestimated. This is known as publication bias. In individual trials, placebo response rates have ranged from 13 52% while for antidepressants the range was 32 70%. Placebo response rates increased by 7% per decade in the 1980s and 90s. 7 Possible explanations for high rates of response to placebo include that: spontaneous improvement occurs over time patients high expectations of treatment predisposes them to respond well initially 1 patients recruited for trials have less severe forms of depression and are more likely to improve spontaneously or with placebo. 8 Data suggest that the proportion of patients who respond to placebo reduces with increasing severity of depression. 1 Rating scales used to measure response include both somatic and mood symptoms. Improvement in physical symptoms can reduce scores without 9, 10 significantly improving core mood symptoms. List four reasons why antidepressant therapy might be considered in a patient diagnosed with moderate to severe major depression I. Patient resistance to non-drug therapy II. Successful treatment of a previous major depressive episode with antidepressant III. No access to non-drug therapy in the patient s area IV. Patient unable to afford the time and/or money for non-drug therapy Page 3 of 8

4 List five factors that influence the choice of antidepressant I. Adverse effect profile of antidepressant II. Prior response to medication III. Risks of drug interactions with other concomitantly administered therapy IV. Safety in overdose V. Simplicity of administration Key Message When using antidepressants continue for at least 6 months after symptoms improve Approximately what proportion of patients with depression will have a satisfactory response to the first antidepressant chosen? 50% Summarize the evidence supporting continued antidepressant therapy for at least 6 months after symptoms have improved Following remission, patients should be continued on the same dose of antidepressant for a further 6-12 months. 1-3 Persistence with therapy to achieve remission and prevent relapse may be more important than initial treatment choice. 3 Relapse is most likely in the early stages of recovery. About 40% of patients with a history of recurrent depression will relapse in the first 6-12 months. A systematic review found that the rate of relapse was halved in those who continue antidepressants compared to those switched to placebo (Odds ratio 0.30; 95% CI, 0.2 to 0.4). 11 To prevent relapse, monitor compliance, response and adverse effects at each visit. 12 Use of treatment protocols, persisting with follow-up for at least 6 months and monitoring (including by trained practice nurses) can improve compliance and reduce rates of depression over 6 12 months. 13 The likelihood of further depressive episodes increases with each recurrence; guidelines state that subsequent episodes require longer maintenance therapy of 2 3 years. 1, 3 When reviewing ongoing need for antidepressant treatment, consider the number of prior episodes, their proximity, related functional impairment and the presence of residual symptoms. 1, 3 Briefly discuss what needs to be considered when Switching antidepressants When switching antidepressants, an appropriate interval should be observed between medications to avoid interactions. Changeover caution is required to avoid adverse effects, the most serious of which is serotonin syndrome. General recommendations are based on the pharmacokinetics of the parent drug and of active metabolites. Discontinuing antidepressants When stopping antidepressants, tapering should be considered, particularly for patients receiving higher doses, those with a prior history Page 4 of 8

5 of discontinuation symptoms and those who develop withdrawal symptoms when the antidepressant is ceased. Write a brief summary of the Geddes paper. 11 One sentence summary The reduction in the absolute risk of relapse is approximately halved when antidepressants are continued for 6-12 months after response, compared to those switched to placebo. Brief overview This was a systematic review of randomized clinical trials of continuing treatment with antidepressants in patients with depressive disorders who have responded to acute treatment. Trials were classified in two ways: I. Duration of treatment before randomization a. 1-2 months b. 4-6 months c. >12 months II. Duration of randomized treatment a. 6 months b. 12 months c months 37 trials (in 82 publications) met the inclusion criteria and for 6 of these trials data was not available. 31 trials (4410 patients) were included in the analysis and of these: 7 provided data for 6 months follow-up 738 patients 11 provided data for 12 months follow-up 2726 patients 3 provided data for 18 months follow-up 240 patients 6 provided data for 24 months follow-up 356 patients 4 provided data for 36 months follow-up 350 patients Relapse is most likely in the early stages of recovery. About 40% of patients in antidepressant trials relapsed in the first 6 12 months after initial improvement, but the rate was halved in those who continued antidepressants, compared to those switched to placebo. (Odds ratio 0.30; 95% CI, 0.2 to 0.4). This was mostly in those with a high risk of recurrence. Key Message Advise patients what to expect from drug therapy: likely adverse effects, up to 4 6 weeks for effect and the expected duration of treatment List five key points that must be explained to patients when antidepressant therapy is initiated I. Some adverse effects are likely (describe what these are), but most will go away after 1 2 weeks. If you are concerned about adverse effects you are experiencing, talk to your doctor rather than stopping treatment. It may Page 5 of 8

6 be possible to reduce adverse effects or to find another antidepressant that suits you better. II. You may not feel better immediately. For some people it can take up to 4 6 weeks to see an effect, so don t give up too soon. III. You may have to try more than one treatment to find one that works for you IV. Don t stop taking antidepressants as soon as you start to feel better. You will need to take antidepressants for at least 6 months. Studies suggest that people who stop treatment too early are more likely to relapse. V. Don t stop taking antidepressants abruptly, especially once you ve been taking them for a month or more. Stopping suddenly can cause unpleasant side effects. Talk to your GP or pharmacist about how to reduce the dose gradually to prevent side effects. List 5 common adverse effects of TCAs Sedation, dry mouth, blurred vision, constipation, weight gain, orthostatic hypotension, urinary hesitancy or retention, reduced GI motility, anticholinergic delirium (particularly in the elderly and in Parkinson's disease), impotence, loss of libido, other sexual adverse effects, tremor, dizziness, sweating, agitation, insomnia SSRIs Nausea and vomiting, diarrhoea, constipation, sleep disturbances (mostly insomnia but somnolence may occur with paroxetine or fluvoxamine), anxiety, agitation, sexual dysfunction, sweating, tremor, rash List 3 common adverse effects for each of the following Mirtazapine Increased appetite, weight gain, sedation, dry mouth, asthenia and peripheral oedema Mianserin Sedation, dry mouth, dizziness and vertigo Moclobemide Nausea, dry mouth, constipation, diarrhoea, anxiety, restlessness, insomnia, dizziness, headache Nefazodone Dizziness, dry mouth, visual disturbance, confusion, sedation, nervousness, agitation, tremor, insomnia, sexual dysfunction, hepatic failure Reboxetine Dry mouth, headache, paraesthesia, dizziness, sweating, tachycardia, increase in heart rate, increase in diastolic BP, insomnia, constipation, hypotension and genitourinary abnormalities (including impotence, ejaculatory dysfunction and urinary retention in men) Venlafaxine Nausea, vomiting, anorexia, headache, sweating, rash, anxiety, dizziness, fatigue, syncope, hypertension (dose-related), orthostatic hypotension, tremor Page 6 of 8

7 Describe the clinical features of serotonin syndrome Mental Neuromuscular Autonomic Confusion, agitation, hypomania, hyperactivity, restlessness Clonus (spontaneous, inducible or ocular) hyperreflexia, hypertonia, ataxia, tremor Hypertonia and clonus are symmetrical and more obvious in lower limbs to begin with. N.B. Clonus is the most important distinguishing feature in diagnosis. Hyperthermia, sweating, tachycardia, hypertension, mydriasis, flushing shivering List 8 drugs that may increase the risk of serotonin syndrome when co-prescribed with a selective serotonin re-uptake inhibitor (SSRI)? Antidepressants Analgesics Over-thecounter drugs Stimulants Anti-migraine drugs Others Illicit drugs Monoamine oxidase inhibitors (MAOIs), mirtazapine, moclobemide, tricyclic antidepressants (TCAs, especially clomipramine and imipramine), venlafaxine Dextropropoxyphene (Doloxene, in Digesic and Capadex), pethidine, tramadol (Tramal, Zydol) Brompheniramine (in Dimetapp), dextromethorphan (cough suppressant), panax ginseng, St John s wort, S-adenosylmethionine (SAMe) Diethylpropion (Tenuate, Tenuate Dospan), hallucinogenic amphetamines, methylphenidate (Ritalin), phentermine (Duromine) Dihydroergotamine (Dihydergot), naratriptan (Naramig), sumatriptan (Imigran), zolmitriptan (Zomig) Buspirone (Buspar), linezolid (Zyvox), lithium (Lithicarb, Quilonum), selegiline (Eldepryl, Selgene), sibutramine(reductil), tryptophan MDMA (ecstasy), LSD, cocaine Key Message Always ask about suicidal thoughts and assess risk, especially during initial treatment For which patients with depression is it appropriate to ask about their thoughts/ideas of suicide? All patients, irrespective of severity What is the likely impact on the risk of suicide of clinicians asking patients about suicidal thoughts? Asking about suicidal thoughts does not cause suicidal behaviour List five risk factors for suicide I. A previous suicide attempt or acts of self-harm II. Being male III. Access to means of suicide (tablets, firearms) IV. Social isolation Page 7 of 8

8 V. Chronic medical illness VI. Diagnosis of: major depression bipolar disorder schizophrenia or schizoaffective disorder alcohol/drug abuse personality disorder current psychosis REFERENCES 1. National Institute for Clinical Excellence. Depression: management of depression in primary and secondary care. Clinical Guideline 23. London: NICE, (accessed 20 June). 2. Psychotropic Writing Group. Therapeutic Guidelines: Psychotropic. Version 5. Melbourne: Therapeutic Guidelines Ltd, Ellis PM, Smith DA, beyond blue: the national depression initiative. Treating depression: the beyondblue guidelines for treating depression in primary care. "Not so much what you do but that you keep doing it". Med J Aust 2002;176 Suppl:S Williams J, Mulrow C, Chiquette E, et al. A systematic review of newer pharmacotherapies for depression in adults: evidence report summary: clinical guideline, part 2. Ann Intern Med 2000;132: Kirsch I, Moore TJ, Scoboria A, et al. The emperor's new drugs: an analysis of antidepressant medication data submitted to the U.S. Food and Drug Administration. Prevention and Treatment 2002; 5. (accessed 15 August 2005). 6. Khan A, Khan S, Brown WA. Are placebo controls necessary to test new antidepressants and anxiolytics? International Journal of Neuropsychopharmacology 2002;5: Walsh BT, Seidman SN, Sysko R, et al. Placebo response in studies of major depression: variable, substantial, and growing. JAMA 2002;287: Parker G, Anderson IM, Haddad P. Clinical trials of antidepressant medications are producing meaningless results. Br J Psychiatry 2003;183: National Institute for Clinical Excellence. CG 23 - Depression Appendix 17. London: NICE, (accessed 20 June 2005). 10. Moncrieff J, Kirsch I. Efficacy of antidepressants in adults. BMJ 2005;331: Geddes JR, Carney SM, Davies C, et al. Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review.[see comment]. Lancet 2003;361: Nolan P, Badger F. Aspects of the relationship between doctors and depressed patients that enhance satisfaction with primary care. J Psychiatr Ment Health Nurs 2005;12: Gilbody S, Whitty P, Grimshaw J, et al. Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA 2003;289: Page 8 of 8