Pharmaceutical Care of People with Depression

Quality Education for a Healthier Scotland

Pharmacy

Pharmaceutical Care of People with Depression


PharmacyObjectives

Provide an overview of the diagnosis and therapeutic management of depression

Identify key pharmaceutical care needs of this group of patients

Explore ways of positively impacting on the care of this patient population


PharmacyNational Programme for Improving Mental Health and Well-being in Scotland

September 2003-2006

Key aims:

Raise awareness and promoting mental health and well-being

Eliminate stigma and discrimination Prevent suicide Promote and support recovery


Pharmacy

Key Facts & Figures

Life-time Prevalence: 1 in 2 women; 1 in 4 men

30% of above with Major Depressive Illness >80% treated in primary care 50-60% of patients respond to 1st line Treatment 25-30% placebo response in controlled trials 20-60% of patients respond to switching between class of

antidepressant or SSRIs 37% of patients relapse within 1 yr. of remission in primary care


PharmacyDepression - Diagnosis by DSM-IV criteria

At least five of the following symptoms (including either 1 or 2) for two weeks andcausing clinically significant distress or impairment in functioning –

Depressed mood Loss of interest or pleasure in almost all activities Significant weight loss or gain, or change in appetite nearly every day Insomnia or hypersomnia Psychomotor agitation or retardation (observable by others) Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Diminished ability to think or concentrate, or indecisiveness Recurrent thoughts of death or suicide


PharmacyDepression - At Risk Patients

Adverse social circumstances Drug and alcohol misuse Physical illness Hospitalised patients Patients Rx musculoskeletal/CNS drugs Postnatal women

Action:refer cases of suspected undiagnosed depression


PharmacyManagement

Options (alone or in combination) Psychotherapy Drug therapy Electro-Convulsive Therapy

Aims of treatment Remission of symptoms to the pre-morbid state Restoration of social and working capacity Reduced risk of relapse and recurrence Prevent suicide


PharmacyChoice of Antidepressant

“There are no clinically significant differences in efficacy between TCAs and SSRIs.”

Geddes JR, Freemantle N et al

SSRIs versus other antidepressants for depressive disorder

The Cochrane Library , Issue No4, 2000

Oxford: update Software (Cochrane review)


PharmacyFactors Influencing Choice

Prominent features of depression Co-existing disease states Interacting drugs Previous response to therapy Individual tolerability to side effects Ability to comply – one daily dosing may be simpler Age of patient Risk of overdose Pregnancy & breast feeding

- Generally SSRI 1st line but not indicated in mild depression


Pharmacy

Mechanisms

Transmission

Post-synaptic Receptors

Pre-synaptic Receptors: Control the release of neurotransmitter

Drug


PharmacyTricyclic Antidepressants (TCAs)

All act on Serotonin and NA but in different proportions

Also hit muscarinic, 1 receptors and histamine receptors – responsible for side effects

Some more toxic in overdose than others

Reserved for 3rd – 4th line these days


PharmacySelective Serotonin Re-uptake Inhibitors (SSRIs)

Serotonergic side effects GI – Nausea, vomiting, dyspepsia Central – dizziness, agitation, insomnia, headache Others – Dry mouth, sexual dysfunction, bleeding disorders, anorexia or

weight loss.

Usually 1st line agentsUseful for patients with physical problems as have good side effect

profile


PharmacyMonoamine Oxidase Inhibitors (MAOIs)

Boost available monoamines by inhibiting breakdown by monoamine oxidase enzyme (centrally & peripherally)

Irriversible inhibitors -Phenelzine, tranylcypromine, Isocarboxazid Consumption of tyramine rich foods or sympathomimetic agents results in hypertensive crisis –

dietary restrictions apply Must not be prescribed with other antidepressants – washout must be observed Risks in elective surgeryReserved as 4th-5th line but useful in phobic patients or those with atypical hypochondriacal or

hysterical features

Reversible inhibitors –Moclobemide- Dietary restrictions less necessary


Pharmacy

Venlafaxine & Duloxetine(SNRIs)

Boost serotonin & NA levels by reuptake mechanism

New monitoring guidelines for venlafaxine – baseline ECG and blood pressure. Not to be used if cardiac risk factors present. ECG & BP monitoring on therapy.

Some evidence to support high doses (225mg) in treatment resistant depression. Still used in secondary care. Associated with raised BP.

Side effects include nausea, insomnia, agitation, restlessness, ECG changes, hypertension, withdrawal effects (even with missed doses)

Duloxetine does not have the same monitoring requirements but not much experience with it yet


Pharmacy

Mirtazapine (NaSSA)

Noradrenergic and specific serotonergic antidepressant

presynaptic 2 antagonist – increases NA and serotonin levels centrally but post synaptically blocks 5HT2 and 5HT3 subtypes so there is a specific action on 5HT1. Less sleep disturbance and less sexual dysfunction

Also histaminergic – responsible for sedation and weight gain Practically no anticholinergic effects and no cardiovascular effects Rarely blood dyscrasias


PharmacyReboxetine (NARI)

Noradrenaline reuptake inhibitor (weak effect on 5HT)

Side effects – insomnia, sweating, dizziness, urinary hesitancy

Can be considered 2nd or 3rd line therapy as favourable side effect profile


PharmacyGeneral Risks of Antidepressant

All antidepressants can cause hyponatraemia (CSM warning) All lower seizure threshold to some extent. All can cause sweating All can cause “switching” in bipolar patients Discontinuation reactions can occur with all antidepressants, but are more

common in short half life agents regardless of class. Combinations of antidepressants are potentially risky and should be used only

under specialist supervision. Switching drugs should be carried out with care.


PharmacyThe Role of the Pharmacist

Reduce stigma by using a responsive pro-active approach Be responsive to possibility of undiagnosed depression Provide information about antidepressants Promote concordance Monitor and provide support to patient & carers Identify adverse effects and interactions (including non-prescribed medication) Discourage self diagnosis and treatment Support people at risk of suicide


PharmacyInitial Prescription for Antidepressant

Reduce stigma - reassure patient depression is a common illness and most patients recover

Emphasise lag period – side effects often present before benefit, encourage to persevere. Discuss discontinuation reactions but reassure that medication is not addictive. Do not stop

abruptly. For SSRIs ensure GP has discussed side effects – patient should report any increase in

suicidal thoughts or increase in agitation or anxiety (may be indicative of akathisia). Discuss common side effects of any antidepressant.

Ensure patient aware of expected duration of treatment.

Result : Improved concordance, reduced potential for relapse.


PharmacyLack of Response/Switching

Ensure adequate trial. Where some response a dose increase may be considered.Usually switch to a different class is indicated, but can switch within a class in certain circumstances

Switching guidelines – In theory it is better to stop and washout one drug before starting another (must do this with

MAOIs) In practical terms this is rarely possible if patient is ill. Potential problems with cross tapering include – antidepressant discontinuation effects,

interactions between the 2 drugs e.g. some SSRIs increase TCA levels, serotonin syndrome (potentially life threatening), cholinergic effects.

If in doubt – seek specialist advice!


PharmacyStopping antidepressants

If stopped abruptly discontinuation symptoms may include – Headaches, restlessness GI symptoms, flu like symptoms, abdominal cramps,

sleep disturbance, anxiety, agitation “electric shock” sensations (particularly with SSRIs)

Common with short half life drugs, rare with fluoxetine

To avoid problems – After < 8 weeks treatment withdraw over 1-2 weeks After 6-8 months treatment taper over 6-8 weeks After long term maintenance, reduce dose by 25% every 4-6 weeks.


Pharmacy

How to Identify and Meet the Pharmaceutical Care Needs

Education checklist for first presentation or changes in dose or medication

Pharmaceutical care needs assessment for depression to identify gaps in patient knowledge, effectiveness, safety and compliance

Implement as part of your own CPD or local project.

Pharmaceutical Care of People with Depression

Documents

Transcript of Pharmaceutical Care of People with Depression