Depression
Dr. Alan Ng
Behavioural Medicine
Reference
Psychiatry in Primary Care
Editors: Goldbloom, Davine
CAMH, Toronto 2011
Objectives
• Discuss the differential diagnosis of depression
• How to screen for depression
• Discuss the DSM V criteria for major depression episode
• Discuss a strategy for psychopharmacology/use of antidepressants
• What is reasonable to expect from a primary care physician in
managing depression?
• When should you refer to a specialist?
What is the differential diagnosis of
depression?
What is the differential diagnosis of
depression?
• Organic conditions
Generally guided by history and examination
Screening bloodwork should normally be CBC (rule out anemia) and
TSH unless otherwise indicated
• ETOH/substance abuse
• medications
What is the differential diagnosis of
depression?
• Grief and major psychosocial stressors (adjustment disorder)
• Bipolar disorder
• Anxiety disorder
• Personality disorder (especially cluster B)
How to make the diagnosis in less than five
minutes
How to make the diagnosis in less than five
minutes
Screening questions (quick screen)
1. In the past month, have you lost interest or pleasure in things you
normally like to do?
2. Have you felt sad, low, down, depressed or hopeless?
If answer ‘yes’ to either question, consider further
exploration/assessment
What are risk factors for Major Depressive
Episode (MDE)?
What are risk factors for Major Depressive
Episode (MDE)?
• Chronic insomnia or fatigue
• Unexplained somatic symptoms
• Chronic medical illness
• Recent cardiovascular event (CVA,MI)
• Recent trauma (psychological or physical)
• Other psychiatric disorder
• Family history of mood disorder
• Extensive use of medical system (‘thick chart syndrome’)
What tools are available to make the
diagnosis?
What tools are available to make the
diagnosis?
• SIGECAPS
• PHQ-9
• Mood Disorder Questionnaire
What is the DSM V criteria for major
depressive episode?
What is the DSM V criteria for major
depressive episode?
A.
• Five (or more) of the following symptoms have been present during
the same 2- week period and represent a change from previous
functioning;
• at least one of the symptoms is either (1) depressed mood or (2) loss
of interest or pleasure.
Do not include symptoms that are clearly due to a general medical
condition, or mood-incongruent delusions or hallucinations.
What is the DSM V criteria for major
depressive episode?
• Depressed mood most of the day, nearly every day, as indicated by either
subjective report (e.g., feels sad or empty) or observation made by others
(e.g., appears tearful). Note: In children and adolescents, can be irritable
mood.
• Markedly diminished interest or pleasure in all, or almost all, activities
most of the day, nearly every day (as indicated by either subjective account
or observation made by others).
• Significant weight loss when not dieting or weight gain (e.g., a change of
more than 5 percent of body weight in a month), or decrease or increase in
appetite nearly every day. Note: In children, consider failure to make
expected weight gains.
• Insomnia or hypersomnia nearly every day.
DSM V criteria for MDE
• Psychomotor agitation or retardation nearly every day (observable by
others, not merely subjective feelings of restlessness or being slowed down).
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being
sick).
• Diminished ability to think or concentrate, or indecisiveness, nearly every
day (either by subjective account or as observed by others).
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide attempt or a specific plan for
committing suicide
DSM criteria for MDE
B. The symptoms cause clinically significant distress or impairment in
social, occupational or other important areas of functioning.
C. The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition (e.g., hypothyroidism).
Source: DSM-V, American Psychiatric Association
Psychopharmacology
What is the goal of acute treatment?
Psychopharmacology
What is the goal of acute treatment?
• Full remission of symptoms
• Return to baseline function
• Can evaluate using PHQ-9, Beck, Hamilton rating scales
How do you decide how to choose an
antidepressant?
How do you decide how to choose an
antidepressant?
• There is no one definite choice as it depends on individual variability
between efficacy and side effects
• Some evidence for increased efficacy with ecitalopram, mirtazepine
and venlafaxine with severely depressed patients
• Some evidence for short-term tolerability with citalopram,
escitalopram, moclobemide, sertraline
How do you decide how to choose an
antidepressant?
• Broad spectrum agent (for both anxiety and depression)
recommended due to high comorbidity for both disorders
Eg escitalopram, paroxetine, sertraline, venlafaxine
(others may also be effective for anxiety disorders but studies have not
been done)
• Bupropion, mirtazepine and moclobamide have fewer sexual side
effects
First line antidepressants
• What would you choose as first line antidepressant?
First line antidepressants
• SSRI-selective serotonin reuptake inhibitors
• SNRI-serotonin and norepinephrine reuptake inhibitors
• Novel action
• RIMA-reversible monoamine oxidase inhibitor
SSRI (CAMH 2011)
SSRI
Usual daily dose
(mg)
citalopram
20-40
escitalopram
10-20
fluoxetine
20-40
fluvoxamine
100-200
paroxetine
20-40
sertraline
50-150
efficacy
tolerability
anxiety
+
+
+
+
+
+
+
Efficacy-based upon meta-analyses and head to head trials
Tolerability-based upon meta-analyses
Anxiety-based on Canadian Anxiety Disorder Treatment Guidelines 2006
+
SNRI
SNRI
Usual daily dose
(mg)
efficacy
tolerability
desvenlafaxine
50-100
duloxetine
60-120
+/-
Venlafaxine-XR
75-225
+
SNRI=serotonin and norepinephrine reuptake inhibitor
anxiety
+
Novel action
Novel action
Usual daily dose
(mg)
Efficacy
Tolerability
Bupropion-SR
150-300
+/-
mirtazepine
30-60
+/-
trazodone
200-400
Anxiety
RIMA
RIMA
Usual daily dose
(mg)
moclobamide
450-600
efficacy
RIMA=reversible monoamine oxidase inhbitor
tolerability
+
anxiety
What are the second line antidepressants?
Second line antidepressants
TCA
amitryptyline
100-250
clomipramine
100-250
desipramine
100-250
imipramine
100-250
nortryptyline
75-150
TCA-tricyclic antidepressants
What are the third line antidepressants?
Third line antidepressant
MAOI
Usual daily dose (mg)
phenelzine
30-75
tranylcypromine
20-60
MAOI: Monaoamine oxidase inhibitor
Maintenance treatment
• What are the goals?
• How long should you continue if patient has no risk factors?
• How long should you continue if patient has risk factors?
Maintenance treatment
• What are the goals?
• How long should you continue if patient has no risk factors?
• How long should you continue if patient has risk factors?
Risk factors: chronic, recurrent, severe or difficult to treat episodes
Maintenance treatment
• What are the goals?
• How long should you continue if patient has no risk factors?
• How long should you continue if patient has risk factors?
• Prevention of relapse and recurrent
• Without risk factors, 4-6 months
• With risk factors, at least 2 years
Stopping medication
• How do you taper?
• What are the common discontinuation symptoms?
• Which medications are most likely and least likely to be associated
with discontinuation symptoms?
Stopping medication
• Gradually taper, at least one week between each dose reduction
FINISH mnemonic:
• Flu-like symptoms
• Insomnia
• Nausea
• Imbalance (dizziness)
• Sensory disturbance (electric shocks)
• Hyperarousal (agitation)
Stopping medication
• Discontinuation symptoms more likely with paroxetine, venlafaxine
• Less likely with fluoxetine, moclobemide
What do you do if there is no response to
treatment?
What do you do if there is no response to
treatment?
• Check diagnosis (?bipolar, substance abuse)
• Optimize dose, increase to max for several weeks, manage sideeffects
• Add psychotherapy
• Switch to another antidepressant
• Augment with augmenting agent
• Augment with atypical antipsychotic agent
• Combine with antidepressant in a different class
Augmenting agents
Augmenting agents
• Triiodotyronine (T3) 25-50 ug/day
• Lithium 600-900 mg/day
Watch for increased side effect burden
Atypical antipsychotics
Atypical antipsychotics
• Olanzepine 2.5-10 mg daily
• Risperidone 0.5-3 mg daily
• Quetiapine 100-300 mg daily
Watch for increased side effect burden
Partial response to treatment
When there is partial response to treatment most clinicians would
augment or combine so not to lose gains from the first antidepressant
(consensus, little evidence)
Is a washout period needed when switching
between antidepressants?
Is a washout period needed when switching
between antidepressants?
• Only to and from MAOIs
How do you approach switching between
antidepressants?
How do you approach switching between
antidepressants?
Two Approaches
1. Start second antidepressant at low dose while tapering off the first
dose
Watch for side effect burden
2. If patient is sensitive to side effects, taper off the first antidepressant
before starting the second
What general advice will you give to a patient
when starting antidepressants?
What general advice will you give to a patient
when starting antidepressants?
• Antidepressants have a lag time of 2-3 weeks to response
• Take medications daily
• Side effects are usually mild and temporary
• Continue on the medication for at least 6 months, otherwise the
symptoms may return
• Do not stop antidepressants before checking with your doctor
Other treatments
• Psychotherapy (CBT, problem solving therapy, analytic therapy)
• Self-management-patient education/involve patient in
plan/workbooks etc
• Exercise
• Light therapy (SAD)
• ECT
What is reasonable to expect from a primary
care physician in treating depression?
What is reasonable to expect from a primary
care physician in treating depression?
• Diagnose and develop a treatment plan
• Assess suicide risk
• Monitor response and outcome using scales (PHQ-9)
• Aim for complete remission of symptoms for acute and maintenance
treatment
• Coach self-management and or use problem solving techniques
• Manage medications-be familiar with at least two classes of
antidepressants and at least one augmentation strategy
• Refer when necessary
When do you refer to a specialist?
When do you refer to a specialist?
• Complicating comorbidity (substance abuse, personality disorder,
anxiety disorder)
• Severe presentation (suicidality, psychosis,bipolar esp with mania)
• Diagnostic clarification needed
• Refractory to treatment (CBT, two or more medication trials)