Medication management of anxiety & depression. Dr Katie Simpson GP Mental health lead East Berks CCG

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Oliver Cook
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1 Medication management of anxiety & depression Dr Katie impson GP Mental health lead East Berks CCG

2 NICE guidelines for Anxiety

3 tepped Care

4 RIs and NRIs in Anxiety disorders RI ertraline Citalopram Fluoxetine Escitalopram Paroxetine Venlafaxine Duloxetine Licensed indication (in addition to major depression) GAD, Panic, AD, PTD Panic OCD GAD, Panic, AD, OCD GAD, Panic, AD, OCD, PTD GAD, Panic, AD GAD

5 Pregabalin in GAD

6 Benzodiazepines Do not offer BDZs for Rx of GAD apart from short-term measures during a crisis. Avoid driving- even the next morning Can become habit forming after 2 weeks In long term can cause rebound insomnia and anxiety

7 Depression & suicide Early diagnosis of depression and prompt effective treatment has a major role in preventing suicide across the population 45% of those successfully completing suicide have seen their GP in the previous month (77% in the previous year) vs 25% under econdary Care Affective disorders (32-47%) particularly depression

8 NICE depression threshold prescribing

9 Network meta analysis of anti depressant efficacy in major depression

10 Efficacy & tolerability of Anti- depressants in major depression

11 Cipriani review: Does not change current NICE guidance: In terms of efficacy, all antidepressants were more effective than placebo. Differences between antidepressants varied for efficacy and acceptability. In head-to-head studies amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine were more effective than other antidepressants. For acceptability, agomelatine, citalopram, escitalopram, fluoxetine, sertraline, and vortioxetine were more tolerable than other antidepressants Amitriptyline, clomipramine, duloxetine, reboxetine, trazodone, and venlafaxine had the highest dropout rates.. 82% of the trials are considered to have a high or moderate risk of bias, with evidence classed as moderate to low certainty.fluoxetine and paroxetine have a higher propensity for drug interactions.* For people who also have a chronic physical health problem, consider using citalopram or sertraline as these have a lower propensity for interactions. Paroxetine is associated with a higher incidence of discontinuation symptoms.

12 Antidepressants in pregnancy 3-10% of pregnant women Most (50-80%) women stop ADs when pregnant Relapse if AD stopped in pregnancy = 68% v. 26% (Cohen et al 2006) (>if several past episodes or recent)

13 RI: Absolute risk for any pregnant women is LOW Are RIs associated with an increased risk of congenital malformations? Conflicting data (- not controlled for obesity, drugs and alcohol, tobacco, psychiatric illness) But MALL ABOLUTE RIK Are RIs associated with neonatal complications? - Probably, usually mild and self limiting Implications of stopping AD s in pregnancy/ Prescribing sub therapeutically - Potential increase in recurrence of depression and effect on mother and baby Avoid Paroxetine - but evidence not strong ertraline appears to result in the least placental exposure Breast feeding < 10% into breast milk, lowest ertraline

14 Early pharmacological approaches to treatment resistant depression

15 Further Mx (NICE) If person is informed and prepared to accept additional side effects, consider augmenting with: Lithium An antipsychotic such as aripiprazole, olanzapine, quetiapine, risperidone Another antidepressant, such as mirtazapine or venlafaxine

16 Network metanalysis of augmentation treatments for resistant depression

17 Relapse prevention Need to continue treatment for at least 6/12 from recovery Continue medication for at least 2 years (If 2+ recent episodes, other risk factors, relapse consequences severe e.g occupation) Psychological interventions: For recurrent depression Individual CBT (16-20 sessions over 3-4 months) OR Mindfulness based cognitive therapy (8 week group)

18 NICE conclusions on antidepressant medication When prescribing, should normally be RI in generic form Discuss all options Address patient concerns, views on tablets and antidepressants, and discuss common myths Gradual effects and need to persevere ide effects and drug interactions Discontinuation symptoms Not addictive Ask about t. John s Wort Review after 2 weeks, then at least monthly If suicide risk or <30years review after 1 week, then frequently

19 Ketamine

20 Ketamine: Rapid alleviation of depression

21 Further experience with Ketamine:

22 ummary For anxiety Psychological treatment is preferred. RIs first line if treatment is needed RI first line medication for depression. Mirtazepine is non- RI alternative witching within or between class is a reasonable option if pt with depression is insufficiently helped by an initial RI Augmentation with low dose Mirtazepine/ Venlafaxine can be offered in Primary Care Augmentation with low dose atypical antipsychotic is effective but adverse effect burden is troublesome. Ketamine might provide symptomatic relief for pts who have persistent depressive symptoms despite multiple trials of psychological and drug treatment

23 Thank you

Medication for Anxiety and Depression. PJ Cowen Department of Psychiatry, University of Oxford

Medication for Anxiety and Depression PJ Cowen Department of Psychiatry, University of Oxford Topics Medication for anxiety disorders Medication for first line depression treatment Medication for resistant