Depression Management Guidelines - Southern …

1 1 Depression Management Guideline Version 6 August 2017 SH CP 110 Depression Management Guidelines Version: 6 Summary: This guideline advises the Management of Depression in patients within Southern Health. Keywords (minimum of 5): (To assist policy search engine) Depression , Depressive disorder, Antidepressant, Antidepressants, SSRI, Lithium, Antipsychotics, Maintenance, Continuation, Treatment Resistant Depression , Dysthymia, ECT, seasonal affective disorder, relapse prevention, suicide, discontinuation, light therapy, CBT Target Audience: All healthcare professionals employed by Southern Health NHS Foundation Trust Next Review Date: May 2020 Approved and ratified by: Mental Health Drugs and Therapeutic Committee Medicines Management Committee Date of meeting: May 2017 19 July 2017 Date issued: August 2017 Author: Dr Jasenka Matekovic, Consultant Psychiatrist Rebecca Henry, Principal Pharmacist Sponsor.

2 Dr Sarah Constantine 2 Depression Management Guideline Version 6 August 2017 Version Control Change Record Date Author Version Page Reason for Change May 2017 Rebecca Henry 6 1 Changed name to Depression Management Guidelines . Added keywords: lithium, maintenance, continuation, dysthymia Changed date and authors May 2017 Alex Weston 6 2 Version control boxes added May 2017 Rebecca Henry 6 3 Changed order of flow chart to make clearer. Changes made to contents of flow diagram as per BAP Guidelines , WFSBP Guidelines and NICE Depression pathway. Changes documented in separate change control document. May 2017 Rebecca Henry 6 4 BAP guideline recommendations: added in suicide risk box that AD may increase non-fatal suicidal ideation/behaviour in adolescents/younger adults, BUT decrease suicide rates. WFSBP guideline: withdraw antidepressants over at least 3 months if had treatment >6months.

3 References table moved to this page and expanded. May 2017 Rebecca Henry 6 5 Changes to content of table as per NICE, BAP and WFSBP Guidelines . Specific changes recorded on separate change record document. Greater referencing. Prostatism removed as a condition. May 2017 Rebecca Henry 6 6 Changes to content of table as per BAP, NICE and Maudsley. Some miscellaneous treatments removed as not felt should be endorsed in Trust guideline due to cost or poor evidence base. July 2017 Cheryl Field 6 7 Added Appendix 1-3 as discussed at MMC 19th July 2017 Reviewers/contributors Name Position Version Reviewed & Date Alex Weston Principal Pharmacist for R&D and OPMH V6 May 2017 Rebecca Henry Principal Pharmacist V6 May 2017 Medicine Management Committee V6 July 2017 3 Depression Management Guideline Version 6 August 2017 Depression Management Guidelines (jointly produced by Primary and Secondary Care) Consider immediate referral to Secondary Care if any of these apply.

4 Considerable risk of suicide, harm to others or severe self neglect, Psychotic symptoms, History of elation or mania, Significant cognitive impairment, Pregnancy, Psychiatric co-morbidity or complex presentation Mild Depression , recent onset Moderate to Severe Depression Dysthymia, or persistent mild Depression longer than 3 months Mild Depression with past history of more severe Depression and/or when it complicates the care of chronic physical health problems Active monitoring, no antidepressant (AD) Review within 2 weeks. Helpful interim measures: education, short CBT course, refer to local IAPT services. Effective interventions include; CBT and structured counselling, problem solving, BA or IPT, structured exercise programme /activity scheduling and guided self-help CBT books on prescription scheme1 and light therapy for Seasonal Affective Disorder3 Acute treatment ysthymia: consider antidepressant (AD) as 1st line Moderate DD: 1st line AD and/or CBT (if available) Severe DD: AD and CBT (if available) Review every 1-2 weeks for 4 - 6 weeks, and regularly thereafter More frequently if increased risk suicide or <30years old1,2 Assessment after 4 weeks3 Partial response to AD Full response to AD Continuation phase (relapse prevention) Continue same AD on the same dose for at least 6-9 months after remission4.

5 Review regularly once symptom free. No response Switch to another AD To prevent long term recurrence in high risk cases Multiple episodes (2 over 5 years, or 3 or more in total) History of severe episode and/or suicidal risk Persistent residual symptoms Presence of other psychiatric disorders treatable with AD ( panic disorder, PTSD, OCD) Presence of chronic medical condition ( after stroke, MI) The duration (at least 2 years or longer) depends on risk factors Maintain the same dose as for the acute phase Consider specialist advice re. need for maintenance No response AD Relapse or recurrence May be self-limiting over 3 months, increasing dose may be effective in the majority of patients3. Check compliance, therapeutic dose, diagnosis and perpetuating factors ( alcohol/drugs/ co-morbidity/psychosocial factors) Partial response3 Continue for 2-4weeks Increase dose Augmentation Be alert to development of: Persistent mild Depression for more than 3 months, or longer (dysthymia) Moderate or severe depressive disorder 4 Depression Management Guideline Version 6 August 2017 Good practice points Response to antidepressant treatment may take up to 4-6 weeks but most commonly occurs at week 1 or 2 Antidepressants should be continued for at least 6 months after treatment response.

6 Consider serotonin syndrome particularly with high dose SSRI, SNRI, TCAs antidepressant combinations and lithium. Symptoms include sweating, tachycardia, fever, hyperreflexia, hypertension, nausea, diarrhea and altered mental state. Onset is usually early on. Consider hyponatraemia with antidepressants, especially SSRIs. Symptoms include nausea, headaches, malaise, or stupor. Risk increased in older and/or female patients. Special consideration should be given to particular patient groups who are more likely to suffer side effects over 65, complex physical problems, LD. Older persons with co-morbid medical conditions may have a poorer response and high risk of relapse3. Less propensity for drug interactions with sertraline and citalopram6 Cross Tapering/switching ADs: Caution required because of limited evidence, it should be determined by clinical needs.

7 Adjust speed according to response. References 1. Prescribing Guidelines : Depression 2. Note 1. Depressive Disorder (DD) ICD10: At least 2 of the following: 1: Depressed mood for at least 2 weeks, most days, most of the time, 2: Loss of interest or pleasure, 3: Decreased energy or increased fatigability Plus at least 2 of the following: 1. Low self-confidence 5. Agitation or retardation 2. Guilt or excessive self-reproach 6. Sleep disturbance 3. Suicidal thoughts or acts 7. Poor or increased appetite 4. Poor concentration or indecisiveness Mild Depression : 5 symptoms in total, and little disability. Moderate Depression : 6 or more symptoms, associated significant disability. * Consider use of rating scales to assess severity PHQ-9 or HADS DYSTHYMIA: At least two years of persistent mild Depression . General Management Always check the risk of suicide.

8 Begin AD treatment carefully, monitor patients closely, and watch for signs of side effects, worsening symptoms, and increased suicidality All pts on ADs should be informed about duration of the treatment, discontinuation symptoms, and that ADs are not addictive Close patient monitoring is important in early stage of Depression , even when not on AD Those at risk of suicide or under 30 should be reviewed after 1 week of starting an antidepressant, and frequently thereafter. There should be specific discussion and monitoring of possible adverse effects early in treatment (initial worsening of anxiety/ agitation or the emergence of suicidal ideation) with all ADs. Discuss the choice of drug and likely benefit/availability of non-drug treatment and side effects. Several therapeutic measures under Active Monitoring can also be considered for other types of Depression .

9 Psychosocial factors should be considered as predisposing, precipitating and perpetuating factors. Educate on a healthy diet/active lifestyle and appropriate sleep pattern (esp. avoid oversleeping). ANTIDEPRESSANT Discontinuation symptoms: May include dizziness, nausea, dysphoria, paraesthesia, anxiety and headaches. Can occur when any AD is abruptly stopped or doses missed. Most frequently reported with paroxetine and venlafaxine, and least often with fluoxetine and agomelatine. They are usually mild and self-limiting but can occasionally be severe. To stop AD: taper over at least four weeks or longer1 If SSRI withdrawal proving difficult consider switching to fluoxetine. Ideally withdraw over at least 3 months if taken AD >6months4 1. National Institute for Health and Care Excellence (NICE): Depression in adults. Recognition and Management (CG 90) October 2009.

10 2. NICE Depression pathway. Accessed via: 3. Cleare et al. Evidence based Guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology (BAP) Guidelines . J Psychopharm 2015; 29(5): 459-525. 4. Bauer et al. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for biological treatment of unipolar depressive disorders. Part 1: Update 2013. World J Biol Psych 2013; 14: 334-385. and update 2015 5. Taylor D, Paton C, Kapur S: The Maudsley Prescribing Guidelines in Psychiatry, 12 Edition (2015) Wiley Blackwell, Chichester 6. National Institute for Health and Care Excellence (NICE): Depression in adults with a chronic physical health problem. Recognition and Management (CG 91) October 2009. 7. Bazire S: Psychotropic Drug Directory 2016. Lloyd-Reinhold Publications 8. National Institute for Health and Care Excellence (NICE): Social anxiety disorder: recognition, assessment and treatment (CG 159) May 2013.