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Antidepressants Made Easy – A Beginner’s Guide To Rock Your Consultations

depression guide (1)

 

Antidepressants Made Easy – A Beginner’s Guide

This is for the doctors and medical students who want to know the latest NICE guidelines about the antidepressants treatment in adults in an easy way.

In this free video, you’ll learn

1. How antidepressants work, why they are prescribed, their effects and side-effects, and alternative treatments.
2. How to choose the appropriate antidepressants and how to withdraw or change them
3. The latest NICE pathway about the antidepressants treatment in adults
4. The patient-friendly way to answer the most common questions asked by the patients.
5. Some example cases, references and sources of further information are added at the end of this webinar.

 

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Depression

  • It is the most common psychiatric disorder
  • it affects nearly 1 in 6 people in the UK
  • By the year 2020, depression is projected to reach second place in the ranking of Disability Adjusted Life Years (DALYs) calculated for all ages
  • It carries a high burden in terms of treatment costs, effect on families and carers and loss of workplace productivity
  • Currently ranked fourth in terms of global disease burden by the World Health Organization (WHO)
  • Be alert to possible depression
  • Particularly in people with a past history of depression or a chronic physical health problem with associated functional impairment

Consider asking people who may have depression two questions, specifically:

  • During the last month, have you often been bothered by feeling down, depressed or hopeless?
  • During the last month, have you often been bothered by having little interest or pleasure in doing things?

If a patient with a chronic physical illness answers ‘yes’ to either question, the following three questions should be asked:

During the last month, have you often been bothered by:

  • Feelings of worthlessness?
  • Poor concentration?
  • Thoughts of death?

It would be useful, however, to remember that the depression is a bio-psycho-social illness and the first priority of assessment and management of it needs to be understanding it’s psychological and social precipitating and perpetuating factors and addressing these.

Screening

Assessing newly diagnosed patients – These tools include:

  • Patient Health Questionnaire (PHQ-9): this is a nine-item questionnaire which helps both to diagnose depression and to assess severity.
  • It is based directly on the diagnostic criteria for major depressive disorder in the Diagnostic and Statistical Manual – Fourth Edition (DSM-IV).
  • It takes about three minutes to complete.
  • Scores are categorised as minimal (1-4), mild (5-9) , moderate (10-14), moderately severe (15-19) and severe depression (20-27).
  • It can be downloaded free from the internet.
  • Hospital Anxiety and Depression (HAD) Scale: despite its name, this has been validated for use in primary care. It is designed to assess both anxiety and depression.

    • It takes about five minutes to complete. The anxiety and depression scales each have seven questions, and scores are categorised as normal (0-7), mild (8-10), moderate (11-14) and severe (15-21)

 

  • Beck Depression Inventory® – Second Edition (BDI-II): this also uses DSM criteria. It takes about five minutes to complete. It is an assessment of the severity of depression and is graded as minimal (0-13), mild (14-19), moderate (20-28) and severe (29-36). It consists of 21 items to assess the intensity of depression in clinical and normal patients. Each item is a list of four statements arranged in increasing severity about a particular symptom of depression. It is also not free but can be purchased from the supplier’s website
  • Other screening tests may be useful in particular situations.  They include:

    • Interview-based tools (such as Kiddie – Sads and Child and Adolescent Psychiatric Assessment) can be used for children and young adults suspected of having depressive illness.
    • The Center for Epidemiological Studies Depression (CES-D )Scale and Reynolds’ Adolescent Depression Scale (RADS) are more suitable for adolescents.
    • The Edinburgh Postnatal Depression Scale (EPDS) – a self-rating scale – is for puerperal depression.
    • The Geriatric Depression Scale (GDS) is suitable for older patients.
    • The Cornell Scale for Depression in Dementia (CSDD) is suitable for patients with dementia.
    • Although screening tools are useful, they should not be a substitute for clinical judgement. The patient’s history, family history and the existence of comorbidities should be taken into account when diagnosing or assessing depression

 

The Stepped-Care Model by NICE

 

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Antidepressant drugs – Choice of antidepressant

Discuss antidepressant treatment options with the person with depression, covering:

  • The choice of antidepressant, including any anticipated adverse events, for example, side effects and discontinuation symptoms and potential interactions with concomitant medication or physical health problems
  • Their perception of the efficacy and tolerability of any antidepressants they have previously taken
  • When an antidepressant is to be prescribed, it should normally be a SSRI in a generic form because SSRIs are equally effective as other antidepressants and have a favourable risk–benefit ratio.

 

Take the following into account:

  • SSRIs are associated with an increased risk of bleeding, especially in older people or in people taking other drugs that have the potential to damage the gastrointestinal mucosa or interfere with clotting.
  • In particular, consider prescribing a gastroprotective drug in older people who are taking non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin.
  • Fluoxetine, fluvoxamine and paroxetine are associated with a higher propensity for drug interactions than other SSRIs
  • Paroxetine is associated with a higher incidence of discontinuation symptoms than other SSRIs.
  • Take into account toxicity in overdose when choosing an antidepressant for people at significant risk of suicide.

    Be aware that:

    • compared with other equally effective antidepressants recommended for routine use in primary care, venlafaxine is associated with a greater risk of death from overdose
    • Tricyclic antidepressants (TCAs), except for lofepramine, are associated with the greatest risk in overdose.

      When prescribing drugs other than SSRIs, take the following into account:

      • The increased likelihood of the person stopping treatment because of side effects (and the consequent need to increase the dose gradually) with venlafaxine, duloxetine and TCAs.

      The specific cautions, contraindications and monitoring requirements for some drugs.

      For example:

      • the potential for higher doses of venlafaxine to exacerbate cardiac arrhythmias and the need to monitor the person’s blood pressure
      • the possible exacerbation of hypertension with venlafaxine and duloxetine
      • the potential for postural hypotension and arrhythmias with TCAs
      • the need for haematological monitoring with mianserin in elderly people.
  • Non-reversible monoamine oxidase inhibitors (MAOIs), such as phenelzine, should normally be prescribed only by specialist mental health professionals.
  • Dosulepin should not be prescribed.

Starting and initial phase of treatment

When prescribing antidepressants, explore any concerns the person with depression has about taking medication, explain fully the reasons for prescribing, and provide information about taking antidepressants, including:

  • the gradual development of the full antidepressant effect
  • the importance of taking medication as prescribed and the need to continue treatment after remission
  • potential side effects
  • the potential for interactions with other medications
  • the risk and nature of discontinuation symptoms with all antidepressants, particularly with drugs with a shorter half-life (such as paroxetine and venlafaxine), and how these symptoms can be minimised
  • the fact that addiction does not occur with antidepressants
  • Offer written information appropriate to the person’s needs
  • For people started on antidepressants who are not considered to be at increased risk of suicide, normally see them after 2 weeks.
  • See them regularly thereafter, for example at intervals of 2 to 4 weeks in the first 3 months, and then at longer intervals if the response is good.
  • A person with depression started on antidepressants who is considered to present an increased suicide risk or is younger than 30 years (because of the potential increased prevalence of suicidal thoughts in the early stages of antidepressant treatment for this group) should normally be seen after 1 week and frequently thereafter as appropriate until the risk is no longer considered clinically important

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Antidepressants available in UK

  • SSRIs: Citalopram (Cipramil), escitalopram (Cipralex), fluoxetine (Prozac), fluvoxamine (Faverin), paroxetine (Seroxat), sertraline (Lustral)
  • Mirtazapine (Zispin)
  • Venlafaxine (Efexor)
  • Tricyclics: amitriptyline, clomipramine (Anafranil), dothiepin/dosulepin, doxepin (Sinequan), lofepramine (Gamanil), imipramine, maprotiline, nortriptyline, trimipramine (Surmontil)
  • Duloxetine (Cymbalta)
  • Trazodone (Molipaxin)
  • Reboxetine (Edronax)
  • Moclobemide (Manerix)
  • MAOIs: Phenelzine, isocarboxazid, tranylcypromine
  • Mianserin, tryptophan, flupenthixol (Fluanxol)
  • Agomelatine (2008)
  • St. John’s wort

Modes of action and receptors

  • SSRIs: 5-HT reuptake inhibition
  • Mirtazapine: increased 5-HT and NE availability, 5-HT2 and 5-HT3 antagonism
  • Venlafaxine and duloxetine: 5-HT and NA reuptake inhibition (venlafaxine variable, duloxetine similar)
  • Trazodone: 5-HT reuptake inhibition and some receptor antagonism
  • Tricyclics: 5-HT and NE reuptake inhibition
  • Reboxetine: Noradrenaline reuptake inhibition
  • Flupenthixol: Autoreceptor inhibition
  • Moclobemide: Reversible MAO-A inhibition
  • MAOIs: Inhibition of MAO-A and MAO-B enzymes
  • Agomelatine: 5HT2C/2B antagonist and melatonin M1/2 agonist

Choosing an Antidepressant

Normally Choose a generic SSRI

  • SSRIs are associated with an increased risk of bleeding. Consider prescribing a gastroprotective drug in older people who are taking NSAIDs or aspirin.
  • Fluoxetine, fluvoxamine 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.

When Choosing Other Drugs

  • The increased likelihood of the person stopping treatment because of side effects, and the consequent need to increase the dose gradually, with venlafaxine, duloxetine and TCAs .
  • The specific cautions, contraindications and monitoring requirements for some drugs .
  • Non-reversible MAOIs, such as phenelzine, combined antidepressants and lithium augmentation of antidepressants should normally be prescribed only by specialist mental health professionals .
  • Dosulepin should not be prescribed.

 

Side effects

If a person with depression develops side effects early in antidepressant treatment, provide appropriate information.

Consider one of the following strategies:

  • monitor symptoms closely where side effects are mild and acceptable to the person or
  • stop the antidepressant or change to a different antidepressant if the person prefers or
  • in discussion with the person, consider short-term concomitant treatment with a benzodiazepine if anxiety, agitation and/or insomnia are problematic (except in people with chronic symptoms of anxiety)
  • this should usually be for no longer than 2 weeks in order to prevent the development of dependence

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Selected antidepressant side effects

  • Anticholinergic – dry mouth, blurred vision, constipation
  • Cardiac – prolonged QTc, postural hypotension, tachycardia,
  • Nausea – initial, start with lower doses
  • Sedation – mostly histaminergic effect
  • Overdose toxicity – cardiac
  • Pro-convulsant – bupropion at >300mg/d
  • Sexual dysfunction —  lower libido, ED, anorgasmia
  • Anxiety (short-term esp. with SSRIs), appetite changes, hyponatremia (except mirtazapine), diarrhoea, headache, sweating (esp. at night)
  • Many can be minimised by starting at lower doses

 

Onset of action of antidepressants

  • Antidepressants don’t take 4 weeks to work
  • 23% of all drug-placebo differences occur within the first week and 57% were apparent by week 2  (s=47, n=8500, d/b, p/c, Pasternak and Zimmerman, J Clin Psych 2005, 66, 148-58)
  • Time to substantial remission may take 4 weeks in clinical trials
  • In 90% cases, substantial improvement occurs within the first 2 weeks but that the benefit continues to build over several weeks.  (review by Mitchell, BJ Psych 2006, 188, 105-6)

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Monitoring

  • People who start on low-dose TCAs and who have a clear clinical response can be maintained on that dose with careful monitoring.
  • If the person’s depression shows no improvement after 2 to 4 weeks with the first antidepressant, check that the drug has been taken regularly and in the prescribed dose.
  • If response is absent or minimal after 3 to 4 weeks of treatment with a therapeutic dose of an antidepressant, increase the level of support (for example, by weekly face-to-face or telephone contact) and consider:
  • increasing the dose in line with the SPC if there are no significant side effects or
  • switching to another antidepressant if there are side effects or if the person prefers
  • If the person’s depression shows some improvement by 4 weeks, continue treatment for another 2 to 4 weeks.

  • Consider switching to another antidepressant if:

    • response is still not adequate or
    • there are side effects or
    • the person prefers to change treatment.

 

Discontinuing or switching antidepressants

Why discontinue or switch antidepressants?

  • Lack of efficacy
  • Adverse effects
  • Patient discontinues of own accord
  • End of maintenance phase

 

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Switching Antidepressants

Factors to consider:

  • Speed at which the switch is needed
  • Current dose of the first drug
  • Individual drugs
  • effects, transmitter effects, kinetics etc
  • Individual susceptibility to (additive) side-effects

Potential problems:

  • Cholinergic rebound
  • Antidepressant discontinuation symptoms
  • Drug-drug interactions
  • Discontinuation effects from the first drug interpreted as side-effects of the second
  • Serotonin Syndrome for drugs affecting serotonin

When switching to another antidepressant, be aware that the evidence for the relative advantage of switching either within or between classes is weak.

Consider switching to:

  • initially a different SSRI or a better tolerated newer-generation antidepressant
  • subsequently an antidepressant of a different pharmacological class that may be less well tolerated, for example, venlafaxine, a TCA or a MAOI
  • Do not switch to, or start, dosulepin because evidence supporting its tolerability relative to other antidepressants is outweighed by the increased cardiac risk and toxicity in overdose
  • When switching to another antidepressant, which can normally be achieved within 1 week when switching from drugs with a short half‑life, consider the potential for interactions in determining the choice of new drug and the nature and duration of the transition

Exercise particular caution when switching:

  • from fluoxetine to other antidepressants, because fluoxetine has a long half-life (approximately 1 week)
  • from fluoxetine or paroxetine to a TCA, because both of these drugs inhibit the metabolism of TCAs; a lower starting dose of the TCA will be required, particularly if switching from fluoxetine because of its long half-life
  • to a new serotonergic antidepressant or MAOI, because of the risk of serotonin syndrome
  • from a non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed routinely during this period).

 

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 Stopping or Reducing Antidepressants

  • Advise people with depression who are taking antidepressants that discontinuation symptoms may occur on stopping, missing doses or, occasionally, on reducing the dose of the drug.
  • Explain that the symptoms are usually mild and self-limiting over about 1 week, but can be severe, particularly if the drug is stopped abruptly.
  • When stopping an antidepressant, gradually reduce the dose, normally over a 4-week period, although some people may require longer periods, particularly with drugs with a shorter half-life (such as paroxetine and venlafaxine).
  • This is not required with fluoxetine because of its long half-life.
  • Inform the person that they should seek advice from their practitioner if they experience significant discontinuation symptoms.

  • If discontinuation symptoms occur:

    • Monitor symptoms and reassure the person if symptoms are mild
    • Consider reintroducing the original antidepressant at the dose that was effective (or another antidepressant with a longer half-life from the same class) if symptoms are severe, and reduce the dose gradually while monitoring symptoms.

 

Assessing depression and its severity

As set out in the introduction to this guideline, the assessment of depression is based on the criteria in DSM-IV.

Assessment should include the number and severity of symptoms, duration of the current episode, and course of illness.

Key symptoms:

  • Persistent sadness or low mood; and/or
  • Marked loss of interests or pleasure.
  • At least one of these, most days, most of the time for at least 2 weeks.

If any of above present, ask about associated symptoms:

  • disturbed sleep (decreased or increased compared to usual)
  • decreased or increased appetite and/or weight
  • fatigue or loss of energy
  • agitation or slowing of movements
  • poor concentration or indecisiveness
  • feelings of worthlessness or excessive or inappropriate guilt
  • Suicidal thoughts or acts.
  • Then ask about duration and associated disability, past and family history of mood disorders, and availability of social support

General Advice and Active Monitoring

Factors that favour general advice and active monitoring:

  • four or fewer of the above symptoms with little-associated disability
  • symptoms intermittent, or less than 2 weeks’ duration
  • recent onset with identified stressor
  • no past or family history of depression
  • social support available
  • lack of suicidal thoughts.

Active Treatment

Factors that favour more active treatment in primary care:

  • Five or more symptoms with associated disability
  • Persistent or long-standing symptoms
  • Personal or family history of depression
  • Low social support
  • Occasional suicidal thoughts.

Referral

Factors that favour referral to mental health professionals:

  • inadequate or incomplete response to two or more interventions
  • recurrent episode within 1 year of last one
  • history suggestive of bipolar disorder
  • the person with depression or relatives request referral
  • more persistent suicidal thoughts
  • Self-neglect

Urgent Referral

Factors that favour urgent referral to specialist mental health services

  • actively suicidal ideas or plans
  • psychotic symptoms
  • severe agitation accompanying severe symptoms
  • Severe  self-neglect

 

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ANTIDEPRESSANTS – swapping and stopping

GENERAL POINTS

Ideally, patients admitted to the acute trust should be maintained on current therapy unless there are compelling reasons to change.

Serotonergic Syndrome (SS)

A syndrome caused by over stimulation of serotonergic mediated enervation in the CNS. Combinations of antidepressants either deliberately or accidentally  may cause SS.

Onset is usually within a few hours of dose changes and can resolve quickly on dose reduction or cessation once symptomology recognized.

Diagnosis is according to Sternbachs Criteria below:  ­

At least 3 mental state changes, agitation or restlessness, sweating, diarrhoea, fever, hyperreflexia, tachycardia, myoclonus, lack of co­ ordination, shivering and tremor.

Nausea, vomiting, tachycardia, hypertension and convulsions have been reported. Rule out other causes of these symptoms such as infection, substance misuse or withdrawal or neuroleptic malignant syndrome.

Rule out other causes of these symptoms such as infection, substance misuse or withdrawal or neuroleptic malignant syndrome.

Causes 

  • Most often with combined or consecutive treatment with SSRIs, tricyclics, MAOIs, tryptophan etc

Treatments

  • Stop drugs – usually resolves in no more than 24 hours
  • Symptomatic measures : e.g. cooling, BDZs

Prevention

  • take care when combining or switching serotonergic antidepressants

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Discontinuation phenomena

Characteristics:

  • Commence within 1-3 days of stopping or reducing doses
  • Usually short-lived (1-2 weeks)
  • Rapidly suppressed by re-introduction of drug
  • Distinct from relapse or recurrence, which occur 2+ weeks after discontinuation
  • Can occur even with missed doses

Tricyclics:

  • Cholinergic rebound
  • headache, restlessness, diarrhoea, nausea
  • ‘flu-like symptoms, cramps
  • lethargy
  • sleep disturbances
  • movement disorders

SNRI (venlafaxine):

  • Fatigue, headache, restlessness, nausea
  • abdominal distension, congested sinuses

“SSRI discontinuation”:

  • Dizziness, light-headedness
  • Sleep disturbances
  • agitation, volatility
  • electric shocks in the head
  • nausea, fatigue, headache
  • ‘flu-like symptoms

Mirtazapine & reboxetine:

  • Little or nothing reported

MAOIs:

  • Confusion, delirium, psychosis

Duration of Treatment at Remission

  • Encourage a person who has benefited from taking an antidepressant to continue medication for at least 6 months and inform them that:
  • this greatly reduces the risk of relapse
  • Antidepressants are not associated with addiction.

Duration of Treatment if at High Risk of Relapse

  • Advise use of antidepressants for at least 2 years.
  • Maintain level of medication at which acute treatment was effective (unless there are adverse effects) if:
  • the person has had two or more recent episodes of depression which caused significant functional impairment
  • they have other risk factors for relapse
  • the consequences of relapse are likely to be severe.
  • After 2 years, re-evaluate treatment with the person, taking into account age, comorbidities, and other risk factors; thereafter re-evaluate as regularly as needed.

 

KEY TO THE FOLLOWING TABLE

· Numbers indicate the number of days to leave between the last dose of the first antidepressant and starting the new antidepressant drug.

· Zero indicates that one drug should be withdrawn completely before starting a new drug, but no wash out period is required.

· CT = Cross Taper, this indicates that drugs can be swapped by cross tapering over a few weeks.

· a = Abrupt switching is possible but not recommended

· b = Do not co­administer Clomipramine and SSRIs or Venlafaxine. Withdraw Clomipramine before starting

· c = Beware interactions with Fluoxetine may still occur for 5 weeks after stopping Fluoxetine because of long half­ life.

· d = See general guidelines on discontinuation symptoms. (19)

· e = Withdrawal effects seem to be more pronounced. Slow withdrawal over 1­3 months may be necessary.

· f = Some authorities recommend a 7-day gap and starting tranylcypromine at half the usual dose for 1 week

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credit: swap and stop

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Resources

MIMS  – Antidepressants, a Guide to Switching and Withdrawing – Click here!

  • Depression in adults (update) (2009) NICE guideline CG90
  • Depression with a chronic physical health problem (2009) NICE guideline CG91
  • For additional considerations on the use of antidepressants and other medications (including the assessment of the relative risks and benefits) for women who may become pregnant, please refer to the British national formulary and individual drug summaries of product characteristics (SPCs).
  • Refer to appendix 1 of the BNF and appendix 16 of Depression in adults with a chronic physical health problem for information on drug interactions.
  • http://patient.info/education/depression
  • NHS Clinical Knowledge :http://www.cks.nhs.uk/depression/goals_and_outcome_measures/qof_indicators
  • The PHQ-9: A New Depression: Diagnostic and Severity Measure – Kroenke and Spitzer -http://www.lphi.org/LPHIadmin/uploads/.PHQ-9-Review-Kroenke-63754.PDF
  • Patient.co.uk – depression : http://www.patient.co.uk/doctor/Depression.htm
  • MIMS switching between antidepressants : http://www.mims.co.uk/news/882430/Switching-Antidepressants
  • Non-pharmaceutical management of depression, Scottish Intercollegiate Guidelines Network – SIGN (January 2010)

 

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Example Cases Discussion

 

Q1: A 39-year-old woman has been taking Fluoxetine 20 mg for mod-severe depression for 2 months. She feels better and now wishes to stop. What’s best?

  • Continue for 6 months then stop
  • Reduce slowly over 4 weeks
  • Reduce to 10mg for 6 months then stop
  • Stop today
  • Stop and refer for CBT

 

Q2: A 70 years old lady comes to see you 3 weeks after her husband’s death. You notice she looks depressed. She reports poor sleep , appetite, loss of pleasure in activities and feelings of depersonalisation. What would you suggest?

  • Sertraline
  • Mirtazapine
  • St John’s Wort with light counselling therapy
  • Careful monitoring and bereavement counselling
  • Any combination of above

Q3: A 30-year-old female patient has been taking citalopram 40 mg daily for 4 weeks for moderate to severe depression. She doesn’t feel there’s much improvement. She has suicidal thoughts but they are transient. She has a history of a drug overdose. She has refused psychological treatment.

Select the single most management option.

  • Amitriptyline
  • Continue Citalopram
  • Sertraline
  • Refer to psychiatrist
  • Mirtazapine

(Already  on max dose citalopram , Mirtazapine better tolerated, newer)

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Example Case.

Candidate Information: George Bush, Age 60

Past Medical History: Type 2 Diabetes Mellitus, COPD

Current Medication: Metformin, Aspirin, Simvastatin, Seretide, Salbutamol

Recent Investigation Results: TSH 3.0, HBA1c 35, FBC no abnormality, U&E no abnormality, LFT no abnormality

 

Actor Instructions:

You are George Bush, a 60-year widower. You feel suicidal and have come today to ask for some sleeping tablets. You plan to commit suicide by taking these with a bottle of sherry.

 

Information freely shared

You have not been sleeping well for the last 6 months and open with the statement ‘ I wonder if you could give me some sleeping tablets’. You have tried some tablets from the chemist such as Nytol and Kalms but nothing seems to work. You have also been trying to read or have a glass of sherry before bed to help you doze off. You feel desperate to get a good nights sleep. 

 

Information shared if asked

  • You go to sleep about 11pm but then wake at about 2 am and then cannot get back off to sleep. You do not sleep during the day.
  • You lost your wife 9 months ago to lung cancer and miss her terribly.
  • You live alone, and have 2 daughters but they live in Spain.
  • You do the cooking, housework and garden yourself but over the past couple of months, you can’t be bothered with it.
  • You cannot work because of your COPD but your finances are adequate to cover your living costs. You used to work as a lawyer, you feel useless because you can’t work anymore.
  • You feel you’re ‘no good for anything’.
  • You have lost your appetite and your clothes have got loose so you think you’ve lost weight.
  • You can’t seem to concentrate on reading the paper or watching tv anymore.
  • You used to meet your friends at the snooker club each week but you haven’t been bothered for months now.
  • You drink a small glass of sherry each night
  • You do not smoke anymore.

 

You reluctantly share the following information if the doctor specifically requests it and you feel the doctor is being empathetic and you have a good rapport

 

  • You have been having suicidal thoughts
  • You have not made any attempts to harm yourself but have been thinking about taking tablets.
  • You were coming today to get some sleeping tablets so you could take them all with a bottle of sherry, you feel like you’ve just had enough and want to end it all.

When the doctor suggests you see the psychiatry team today you agree as you say you realise you need some help.

The Examiners Notes

This is an example of a depression consultation. The candidate is expected to identify this gentleman as depressed and to screen him for suicidal thoughts and risk. This consultation gives the candidate an opportunity to demonstrate their interpersonal skills. A good candidate will  show empathy and understanding coming to a shared management plan. Same day referral is expected.

Data Gathering  

(The examiner will look for the following points)

• Structured history taking (details of an appropriately focused history are given in the topic summary)

• Sleep history

• Depression screening questions

• Assessment of risk factors for suicide

• Social history

• Identification of a trigger factor -wife dying

• Alcohol use

• Suicide history

• Hidden agenda- has come for sleeping tablets to use to try and commit suicide

Interpersonal Skills 

(The examiner will look for the following points)

• Use of active listening skills

• Use of silence

• Gentle encouragement

• Rapport

• Empathises

• Patient-centered

• Tries to make eye contact

 

 

Clinical Management 

(The examiner will look for the following points)

• Identifies the patient is depressed and suicidal

• Recognises the need for the patient to be seen by Crisis Team today

• Refers to crisis/psychiatry

 

Negative Indicators

• Failure to ask depression screening questions

• Failure to identify active suicidal ideation and make an appropriate referral for same day assessment.
• Prescription of sleeping tablets

 

Topic Summary – Depression

Case Focus

This case assesses the candidate’s understanding and management of depression and suicidal ideation.

Core Knowledge:

• Depression is found in 10% of those aged over 60. Depression in this group is associated with an increased mortality and is more often missed than in younger groups.

 

Identifying Patients at Risk of Depression (consider depression in patients with;)

• A history of depression, suicide attempt, or any form of abuse (sexual, physical, or substance).

• Significant physical illness (such as coronary heart disease, diabetes, chronic pain).

• Other mental health problems, such as dementia.

• A family history of depression.

• Other potential clues, such as frequent visits to the GP or emergency department.

• Low mood

• Loss of interest or pleasure in activities

• Fatigue/loss of energy

• Worthlessness/excessive or inappropriate guilt

• Recurrent thoughts of death, suicidal thoughts, or actual suicide attempts (actively seek out symptoms by asking about suicidal thoughts and current intent i.e. ‘Do you ever think about suicide’, Have you made any plans for ending your life’).

• Diminished ability to think/concentrate or indecisiveness

• Psychomotor agitation or retardation

• Insomnia/hypersomnia

• Significant appetite and/or weight loss

 

Two Question Screening Tool For Depression

During the last month have you often been bothered by:

• Feeling down, depressed, or hopeless.

• Having little interest or pleasure in doing things?

Positive responses to both questions is 97% sensitive and 67% specific for depression.

 

Risk Factors for Suicide

Social Characteristics

•  Male gender

•  Young age (< 30 years)

•  Advanced age (>60)

•  Single or living alone

 

History        

•  Prior suicide attempt(s)

  Family history of suicide

  History of substance abuse

•  Recently started on antidepressants

•  Hopelessness

•  Psychosis

•  Anxiety panic attacks

•  Concurrent physical illness

•  Severe depression

 

Clinical Features

•  Psychosis

•  Agitation

•  Panic attacks

•  Concurrent physical illness

•  Severe Depression

 

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Management Options

Mild – Severe Depression without active Suicidal Ideation

• Watchful waiting is recommended for mild depression, arrange further assessment – normally within 2 weeks. The following treatment options should be discussed for mild-moderate depression:

• Sleep hygiene (avoid  stimulants e.g. caffeine, nicotine, use bedroom only for sleeping, quiet period 30min prior to bed, avoid sleeping in the daytime, write worries down on to do list before bed time) and anxiety management.

• Exercise (3 sessions per week of moderate duration i.e. 45 minutes to 1 hour for between 10 and 12 weeks).

• Guided self-help provision of appropriate written materials and limited support over 6 to 9 weeks

• Computerised cognitive-behavioural therapy (NICE recommended programmes include Beating the Blues and FearFighter – available via your PCT)

• Psychological interventions (problem-solving therapy, brief CBT and counselling) of 6 to 8 sessions over 10 to 12 weeks

Selective Serotonin Reuptake Inhibitors (SSRIs)

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line antidepressants (better tolerated, less side effects than tricyclics). SSRIs should be stopped gradually (over a 4 week period) due to the risk of withdrawal symptoms/recurrence of low mood. Effects are no greater than placebo in mild depression (PLoS Medicine Feb 2008 meta-analyses).  Sertraline is the most effective and has least side effects – citalopram is almost as good.

Patients who have had two or more depressive episodes in the recent past, and who have experienced significant functional impairment during the episodes, should be advised to continue antidepressants for 2 years.

CBT should be considered for patients with recurrent depression who have relapsed despite antidepressant treatment, or who express a preference for psychological interventions. A combination of CBT and antidepressants is recommended for severe depression.

Suicide risk should be assessed at each appointment and documented. If patients fail to attend appointments they should be followed up. Two-thirds of suicide cases visit the GP in the month prior to suicide.

 

Active Suicidal Ideation

• Refer urgently actively suicidal patients (same day assessment)

• Assess the toxicity of the prescribed medication and quantities

• Consider available support

• Advise on how to access support if their situation deteriorates.

• Advise family members and carers to be vigilant for suicidal ideation

• Arrange follow-up

• Patients with depression started on antidepressants who are considered at risk of suicide OR younger than 30 years should be followed up after 1 week (or sooner if clinical judgement indicates this is more appropriate)

 

SUMMARY

  • Be alert to the presence of depression, particularly in high-risk groups.
  • Two point depression screening is a useful tool.
  • Take a thorough history and perform a comprehensive risk assessment
  • Specifically, enquire about suicidal thoughts

 

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