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Mid Essex CCG 'Guidance for the Treatment of Depression in Adults'

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Mid Essex CCG 'Guidance for the Treatment of Depression in Adults' Guidance for the treatment of depression in adults MILD DEPRESSION - Medication is not first-line treatment or only treatment for depression Actively monitor symptoms, give life style advice, guided self- help or exercise MODERATE DEPRESSION Consider psychological intervention. This is accessed by referral or self-referral to Mid Essex IAPT (Improving Access to Psychological Therapies) and include Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT) Ask about OTC/Herbal/St John’s Wort use – NO SSRI to be prescribed if already on St John’s Wort or stop St John’s Wort Consider referral to specialist care early if the patient has significant suicidal ideation, severe depression, depression in bipolar disorder. MODERATE to SEVERE DEPRESSION Discuss medication and treatment options with patient before prescribing, include side effects and risk of suicidal thoughts during onset of treatment. Consider patients co-morbidities when selecting antidepressant and ask about OTC/Herbal/St John’s Wort as described above. Refer to IAPT - Psychological therapies should be continued alongside medication. Ensure adequate duration of treatment has been tried before switching medication or increasing dose. CITALOPRAM 20mg daily or SERTRALINE 50mg daily Citalopram – consider Dose 10mg for 10days then Assess efficacy over 6-8 weeks. If effective see box 1 titration 20mg for 6-8 weeks Ineffective Sertraline – consider Poorly 25mg for 10days then tolerated 50mg for 6-8 weeks Increase to: Citalopram 30mg OD, Switch to fluoxetine or increase to 40mg after 6 line another SSRI or Mirtazapine. st weeks if required (MAX dose 1 Cross-taper when switching. Box 1. in elderly = 20mg) Increase to therapeutic dose. Sertraline 100mg OD, WHERE increase to 150mg after 6 Assess over 4-6 weeks TREATMENT weeks if required If effective see box 1 Assess over 4-6 weeks IS EFFECTIVE If effective see box 1 Continue for 4-6 Ineffective or Poorly months at same Ineffective tolerated dose. or Poorly tolerated Elderly 1 year. In recurrent Venlafaxine tablets 37.5mg – 225mg: depression 2 Switch to fluoxetine Check cardiac status and BP at initiation. years. or another SSRI or Check BP 1 week after a dose change Mirtazapine. Cross- Poorly tolerated If once daily modified release is required prescribe Vensir XL taper when Then slowly taper (prolonged release) when possible. dose down and line switching. d Tricyclic antidepressant – lofepramine 70mg-210mg n Increase to stop. 2 (least cardiotoxic TCA) therapeutic dose. If effective see box 1 (see Appendix 1) Assess over 4-6 weeks If effective see box 1 Ineffective or Poorly tolerated Refer to specialist if not already referred Any 2nd line agent not already tried OR refer for one of the following Specialist initiation only treatments: Venlafaxine above 300mg – ECG and BP monitoring ECT Combination of SSRI and mirtazapine For very Vortioxetine severe and Augmentation with Lithium or Sertraline line treatment Agomelatine resistant 3rd Duloxetine Phenelzine – need full counselling on MAOI interactions. Second line option in atypical depression depression Quetiapine - in refractory/severe depression or psychotic depression (INPATIENT)Page 1 of 6 DepressionGUI201611V2 0FINAL If effective see box 1 Restricted antidepressants Anti-depressants that do not appear in the flow chart are non-formulary if you are asked to prescribe refer back to the Medicines Optimisation/Management Team. General principles in treatment of depression Evidence shows that patients who are diagnosed with depression face a significant risk that their depression will recur over time and those repeated episodes become more difficult to treat. This highlights the importance of treating the initial episode adequately in conjunction with psychological therapy and reviewing the patient in order to reduce the risk of subsequent depressive episodes. Mild depression — Antidepressants should not be prescribed for mild depression due to the poor risk-benefit ratio and evidence that for many people with mild depression, there is little clinically-relevant difference between treatment with an antidepressant and placebo. Antidepressants may be considered for people with mild depression with persistent symptoms despite following other interventions. Moderate-to-severe depression — antidepressants are effective for treating people with moderate or severe depression. Prescribing antidepressants is only one aspect in the recovery process in the treatment of depression. When starting an antidepressant: Consider suicide risk and toxicity in overdose. Patients, (especially those aged 30 years and under), should be asked directly about suicidal ideation and intent to harm, particularly during high-risk periods such as during initiation of, and changes to, medication. A maximum of one week’s medication should be considered for those assessed at risk. Caregivers should be aware of the need to monitor for the emergence of suicidal thoughts and behaviour and seek medical advice immediately, especially at the start of treatment, during dose changes and when antidepressant treatment is being changed. Explain that symptoms of anxiety may initially worsen. Explain that antidepressants take time to work. Explain that antidepressants should be continued for at least 6 months following remission of symptoms, as this greatly reduces the risk of relapse. Follow up: The review period should be determined by the risk of suicide and the need to assess the tolerability and effectiveness of any treatments started or changed. In general, for people not considered to be at an increased risk of suicide: Arrange an initial review: o Within 1 week for people less than 30 years of age who have been started on an antidepressant. o Within 2 weeks for other people. Arrange subsequent reviews every 2–4 weeks for the first 3 months and if the response to treatment is good, longer review intervals can be considered. Treatment Duration Patients with a single episode should be treated for at least 6 months (as an absolute minimum) after resolution of symptoms. Those who have experienced multiple episodes in the recent past should be advised to continue antidepressants for at least two years after remission. Page 2 of 6 DepressionGUI201611V2 0FINAL Other physical co-morbidities If the person has a chronic physical health problem: Sertraline may be preferred, because it has a lower risk of drug interactions. If an SSRI is prescribed, consider gastro-protection in older people who are taking non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin. Coronary Heart Disease SSRIs are the agents of choice in CHD. They are generally well tolerated, effective and safe to use in patients with CHD when appropriate precautions are taken. Sertraline is safe post MI and considered the drug of choice in these patients. Cardiac rhythm disorders—QT interval prolongation Some SSRIs are associated with prolongation of the QT interval on the ECG trace. Citalopram prolongs the QT interval in a dose-dependent fashion. To a lesser extent, the concern has also been raised for fluoxetine. Sertraline is associated with QT interval prolongation but the evidence is less well established. There is little compelling evidence that recommended doses of other SSRIs prolong the QT interval. Prolongation of QT interval can, in rare cases, result in ventricular tachyarrhythmias such as potentially life- threatening torsades de pointes and in sudden death or Sudden and transient loss of consciousness (syncope). Citalopram should not be used with other drugs that prolong the QT interval. In patients at particular risk of QT-interval prolongation citalopram or fluoxetine should either be avoided or used with caution and after assessing the ECG and measuring plasma electrolytes. These patients should continue to be watched for signs and symptoms of arrhythmias during treatment. ECG assessment should be considered when increasing the dose of the antidepressant. Side effects Many side effects can occur, the common ones being nausea, anxiety and sleep disturbance. Side effects usual last no more than 14 days – patients should be reassured of this and explained. If necessary reduce the dose and re- titrate up again gradually, if intolerable side effects occurs switch to one less likely to cause the effect, attempt non- drug treatments, or symptomatic treatment Use of antidepressants in pregnancy and breastfeeding Decisions about treating depression during pregnancy should be made on an individual basis, taking into account the risks and benefits of the options available to the woman. Involve the woman, and her family where appropriate, in all decisions about treatment. Discuss: - The risks of stopping antidepressants abruptly. - The risks associated with not treating depression during pregnancy. Explain that psychiatric illness during pregnancy is an independent risk factor for congenital malformation, preterm delivery, and perinatal mortality. - The possibility that there may still be a risk of malformations if a drug with known teratogenic risk is stopped as soon as pregnancy is confirmed. - The treatment options available to the woman (no intervention ['watchful waiting'], psychological treatment, antidepressant treatment, or a combination of psychological and antidepressant treatment). If a patient is to remain on an antidepressant they should be referred to a psychiatrist, and support will be arranged. Before pregnancy: If mild or no symptoms for 6 months or longer, consider tapering and discontinuation before conception.
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