Future Proofing

Reducing the Risk of Recurrent Depression

Rob Shieff

Disclosures

None

Depression – a diagnostic look

At least 2 weeks

Low mood Anhedonia

Sleep Appetite / Weight Fatigue Activity Self-worth Thoughts of death Thinking / Concentration / Decision making

Distress / Impairment

No other explanation

Low mood Anhedonia

Appetite

Insomnia

Fatigue Activity

Self-worth

Concentration

Suicide

Sexual problems

AnxietyVocationalProblems

Anger

Relationship problems

Pain and MUSD and A

The 5 Rs

Response, Remission, Recovery, Relapse and Recurrence

SEVERITY

Normal

Symptoms

Syndrome

TREATMENT PHASE

Acute Continuation Maintenance

16 weeks 12 months 12 months

Response

Remission

Relapse

Chronicity

Recovery

Recurrence

Presentation

PartialRemission

The Size of the Problem

New Zealand : Life-time prevalence = 16%

World wide : Prevalence varies widely

USA : 17 %

Japan : 3 %

Gender : Female : Male = 2 : 1

Risk for Depression Accumulates

Lifetime risk for First Episode = 16%

Risk for recurrence after 1 episode = 50%Risk for recurrence after 2 episodes = 65%Risk for recurrence after 3 episodes = 70%

Intensity of Recurrent Episodes Increases

What does this mean ?

Managing Depression is a Two Target Process

Treat the current episode

Make sure that this is

the last episode

The first step in preventing recurrence

Treat the current episode to REMISSION

Gone

or

Very few / Very mild

Symptoms Functioning

Normal

Why is Remission so important?

Partial response without remission is associated with :

Impaired Quality of Life

lower work productivity / worse social functioning

intensification of other psychiatric / physical health problems

greater health care use

higher suicide rate

• Higher Risk of Recurrence

Treatments won’t work if they’re not used

We can increase adherence by offering :

1. Support

2. Information

Realistically optimistic – probable benefit and time-frame

Accurate and specific – side-effects : type and management

Weeks

side-effects

benefit

Securing Remission

• Make it a shared goal

• Treat comprehensively

• Treat aggressively and tenaciously

• Target adherence

Game Breaking Side - effects

Weight gain

Sexual dysfunction

Fighting against weight gain

Patients can’t put on 10kg if you don’t let them put on 5kg

5

1. Dry mouth Calories in drinks Water or low calorie drinks

2. Calmer / less agitated Burn fewer calories Exercise

3. Hungrier / Lose the feeling of fullness 3 meals / smaller portions5 – 6 small meals / protein

Topiramate

4. Carbohydrate craving Low GI carbsLimit carbs after lunch

5. Metabolic shift MetforminGarcinia cambogia

Problems Solutions

Eat your breakfast yourself , share your lunch with your friends and give your dinner to your enemies.

Sexual Dysfunction

You won’t find out if you don’t ask

Symptoms of

Depression

Side – effects of Medication

Interest / Arousal / Orgasm

Offenders

/ Venlafaxine > TCAs > OthersSSRIs

Paroxetine > The Rest

Strategies

• Wait Wait Wait

• Reduce dose ( beware relapse )• Drug holiday ( beware withdrawal )

• Add : Sildenafil ( Men and Women )

BupropionMirtazapine

Ginkgo biloba

• Switch : BupropionMirtazapine

Duloxetine

Preventing Recurrence

Comprehensive Care

MEDICATION PSYCHOLOGY LIFE - STYLE

Managing Medication Into the Future

How much?

How long?

Carry on with whatever it took to get fully better

At least 6-9 months following recovery

Mood

Time

(months)

55%

20%

35%

The Case for Longer Term Treatment

Recurrent Depressions are likely to recur

Recurrence rates are higher with medication alone

Psychological / Life-style factors are protective

Extend treatment if : Multiply recurrent / Severe

Unable or unwilling to add other strategies to pills

New evidence may support life-long treatment in all cases

Depressions occur while on medication

RESILIENCE

Non-medication Approaches

Knowledge

Complementary Medicine

• St. John’s Wort ( Hypericum perforatum )

• Omega 3 Fatty Acids

• S – Adenosylmethionine ( SAMe)

• Inositol

• Resveratrol

• Magnesium

• Vitamin D

Manage Stress

Drugs and Alcohol

AlcoholIdeally : zero

Realistically : 2 – 3 Alcohol Free Days each week

3 – 4 standard units on drinking days

DrugsIdeally : zero

Realistically : depending on the drug - as low as negotiable

CaffeineIdeally : zero

33 units7 units

1.6 units

1.3 units

Life - style

Structure Balance

Activity Scheduling

C B T

Depression : The Lost Disorder

Loss of :

Interest

Energy

Joy

Confidence

Enthusiasm

Motivation

Concentration

Will

Purpose

WITHDRAWL

INACTIVITY

The Worse I Feel

The Less I Do

Consequences

If we stop doing the things that make us feel happy, we tend to stop feeling happy

“ I’ve got to stop these pills ….. they’re making me feel flat ”

We are what we do …… If we stop doing, we loose worth / valueThe less we do the more empty space we create in our livesWhen we do less, we tend to lose structure and balance in our lives

Antidepressants are anti-sad pills, they are not happy pills

Happiness is a by-product of what we do

Take one day at a time

Break the day into hourly blocks

Match activities to times

Model together, apply at home

Best done just before bed

Review today ~ plan tomorrow

Brighter mood

Ready for the morning

Tomorrow

6-7

7-8

8-9

9-10

10-11

11-12

12-1

1-2

2-3

3-4

4-5

5-6

6-7

7-8

8-9

9-10

10-11

The Process

Sleeping

Eating

Add in appointments

Plan for:

Exercise ( ~ 30 - 40 min )

and / or

Relaxation ( ~ 20 - 30 min )

Tomorrow

6-7

7-8

8-9

9-10

10-11

11-12

12-1

1-2

2-3

3-4

4-5

5-6

6-7

7-8

8-9

9-10

10-11

The BasicsThe Crucial Extras“Achievement” Activities

THINGS I NEED TO DO

Things you enjoy once they’re done

• Try to do 2 – 3 each day

• WORK

• Jobs or tasks from a “ To Do” List

Wake up

Go to Bed

Breakfast

Lunch

Dinner

Walk

Meditation

Load of Washing

Cooking

Do the Dishes

To Do List

Recurring Things :

• Cooking

• Cleaning

• Washing

• Shopping

One – Off Things :

• Sort the IRD

• Prune the roses

In bits

“Pleasant” Activities

THINGS I LIKE TO DO

Things you enjoy while you’re doing them

• Try to do 2 – 3 each day

• Harder to find :

“ What did you use to like to do ? ”

“ What do your friends like doing ? ”

“ What have you always wanted to do ? ”

Stroll around a big book shop

Coffee with Kate

Reading

Watch DVD with Paul

Go to the doctor

Sleep Hygiene

RoutineAfternoon exerciseEarlyish dinnerSupperHot shower / bathHerbal remediesDark and quietBed for sleep only

Manage Physical Health and Pain

Crucial Basic Psychological Strategies

A Stitch in Time

Early Warning Signs

Action Planning

Early Warning Signs

Onset of Depression is often a slippery slope

Future episodes tend to mimic past episodes

The earlier you spot it, the easier it is to stop it

Symptom profiles tend to be idiosyncratic

Help the patient identify their early signs of a slip

Remember that early changes are often more obvious to someone else

Make a list and use it as a reference

• shift of sleeping pattern

• irritability

• sense of humour goes

• singing in the shower stops

• misses gym sessions

Action Planning

If you know what to look out for

You keep your eyes open

You take action early

You are more likely to stay well

• Let other people know

• Look for precipitating stress and deal with it

• Keep active and busy

• Fight negative thoughts

• Be prepared to review medication options

A common problem with most therapies

The more you think about your thoughts and feelings, the worse you feel

A solution

A Therapy Wind-shift

anxiety

peace

Mindfulness Meditation

Acceptance and Commitment Therapy

( ACT)

misery

A couple of thoughts about thoughts

We all have negative thoughts from time to time

Is there a difference between :

I made a mess of that I made a mess of that

I don’t know why I bother

I never do anything right

No wonder no-one likes me

I made a mess of that

It’s not our thoughts and feelings that get us into trouble

It’s the way we think and feel about our thoughts and feelingsthat does the damage

Unless we’re careful, we tend to think our thoughts are facts

Re : Medication

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Cateye PC

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Term 2 :

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Junk Thoughts

Thoughts to think about

Helpful

Un-helpful

Mindful inattention

Take action

Review and - if need be - take action

Sorting Thoughts

… that’s all from me