Medication management of anxiety & depression Dr Katie Simpson GP Mental health lead East Berks CCG S NICE guidelines for Anxiety Stepped Care SSRIs and SNRIs in Anxiety disorders SSRI Licensed indication (in addition to major depression) Sertraline GAD, Panic, SAD, PTSD Citalopram Panic Fluoxetine OCD Escitalopram GAD, Panic, SAD, OCD Paroxetine GAD, Panic, SAD, OCD, PTSD Venlafaxine GAD, Panic, SAD Duloxetine GAD Pregabalin in GAD Benzodiazepines S Do not offer BDZs for Rx of GAD apart from short-term measures during a crisis. S Avoid driving- even the next morning S Can become habit forming after 2 weeks S In long term can cause rebound insomnia and anxiety Depression & suicide S Early diagnosis of depression and prompt effective treatment has a major role in preventing suicide across the population S 45% of those successfully completing suicide have seen their GP in the previous month (77% in the previous year) vs 25% under Secondary Care S Affective disorders (32-47%) particularly depression NICE depression threshold prescribing Network meta analysis of anti depressant efficacy in major depression Efficacy & tolerability of Anti- depressants in major depression Cipriani review: Does not change current NICE guidance: S In terms of efficacy, all antidepressants were more effective than placebo. S Differences between antidepressants varied for efficacy and acceptability. S In head-to-head studies amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine were more effective than other antidepressants. S For acceptability, agomelatine, citalopram, escitalopram, fluoxetine, sertraline, and vortioxetine were more tolerable than other antidepressants S Amitriptyline, clomipramine, duloxetine, reboxetine, trazodone, and venlafaxine had the highest dropout rates.. S 82% of the trials are considered to have a high or moderate risk of bias, with evidence classed as moderate to low certainty S .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. S Paroxetine is associated with a higher incidence of discontinuation symptoms. Antidepressants in pregnancy S 3-10% of pregnant women S Most (50-80%) women stop ADs when pregnant S Relapse if AD stopped in pregnancy = 68% v. 26% (Cohen et al 2006) (>if several past episodes or recent) SSRI: Absolute risk for any pregnant women is LOW S Are SSRIs associated with an increased risk of congenital malformations? Conflicting data (- not controlled for obesity, drugs and alcohol, tobacco, psychiatric illness) But SMALL ABSOLUTE RISK S Are SSRIs associated with neonatal complications ? - Probably, usually mild and self limiting S Implications of stopping AD’s in pregnancy/ Prescribing sub therapeutically - Potential increase in recurrence of depression and effect on mother and baby S Avoid Paroxetine - but evidence not strong S Sertraline appears to result in the least placental exposure S Breast feeding < 10% into breast milk , lowest Sertraline Early pharmacological approaches to treatment resistant depression Further Mx (NICE) If person is informed and prepared to accept additional side effects, consider augmenting with: S Lithium S An antipsychotic such as aripiprazole, olanzapine, quetiapine, risperidone S Another antidepressant, such as mirtazapine or venlafaxine Network metanalysis of augmentation treatments for resistant depression 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) NICE conclusions on antidepressant medication S When prescribing, should normally be SSRI in generic form S Discuss all options S Address patient concerns, views on tablets and antidepressants, and discuss common myths Gradual effects and need to persevere Side effects and drug interactions Discontinuation symptoms Not addictive Ask about St. John’s Wort S Review after 2 weeks, then at least monthly S If suicide risk or <30years review after 1 week, then frequently Ketamine Ketamine: Rapid alleviation of depression Further experience with Ketamine: Summary For anxiety Psychological treatment is preferred. SSRIs first line if treatment is needed SSRI first line medication for depression. Mirtazepine is non- SSRI alternative Switching within or between class is a reasonable option if pt with depression is insufficiently helped by an initial SSRI 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 Thank you [email protected] .