1. THE PHILIPPINE COLLEGE OF PSYCHOPHARMACOLOGY 2008 MAJOR DEPRESSION (Featuring the LAPEL method) TEACHING MODULE FOR THE PRIMARY CARE PHYSICIANS

2. 2 OBJECTIVES At the end of the module, the primary care physician is expected to: 1. recognize the important features of major depression using the LAPEL method 2. use appropriately the various antidepressant drugs using the STEPS approach 3. apply these knowledge and skills with confidence in his daily clinical practice

3. 3 FACTS ABOUT DEPRESSION Lifetime prevalence rate of 10 - 25% for females and 5 - 12% for males Highest rates between 25 - 44 years old 1.5 - 3x greater risk in patients with a (+) family history Probable cause: depletion of serotonin and noradrenaline at the synapses

4. 4 9% of patients in primary care settings 30% of acutely hospitalized adults 40% of older patients in long-term care 80% of severely depressed patients think of suicide Depression in Primary Care Setting

5. 5 RISK OF SUICIDE The greatest risk in major depression Very important: always ask for suicidal ideas/attempts; be wary of ‘smiling depressives’ 15% in untreated patients; 4% among patients with treatment 60% of patients talk about it before doing it; never ignore even when it’s attention-seeking Men more successful than women (but more women attempt it)

6. 6 MAJOR DEPRESSION : can be difficult to diagnose in the primary care setting A diagnostic tip: Patients who complain of vague, multiple, non-physiologic, somatic complaints are likely to have a depressive illness (so- called “masked depression”) or an anxiety disorder

7. 7 Five questions to ask in a patient suspected to have Major Depression (The LAPEL Method – PCPsych 2006 ) Low mood (depressed, sad) * Anhedonia (loss of interest/pleasure) * Poor appetite (with weight loss) Early awakening (2-3 hours earlier) Low self-esteem (hopeless, guilty, suicidal) * most important features

8. 8 LAPEL QUESTIONS Low Mood “Have you felt sad or depressed the last few weeks? What part of the day you feel more sad?” Anhedonia “Have you lost interest in things you used to enjoy? Poor appetite/weight loss “ How’s your appetite? Any weight loss?”

9. 9 LAPEL QUESTIONS Early Awakening “What time do you wake up in the morning? How long before you sleep again? Low self-esteem “Have you felt hopeless recently? Do you feel guilty about anything? Have you thought of suicide at all? Any attempts?”

10. 10 LAPEL METHOD (PCPsych 2006) A positive response to three out of five questions means the patient is most likely depressed 96% sensitive* 94% specific* Two of the three positive responses should be low mood and anhedonia (loss of interest) (*Brody and Spitzer, 2002)

11. 11 MAJOR DEPRESSION Treatment Strategies (including the STEPS approach) Antidepressants- TCAs, SSRIs, SNRIs / NaSSA Psychotherapy Electro-convulsive treatment (ECT) Combination Rx

12. 12 ANTIDEPRESSANTS  The most important treatment  Antidepressants increase levels of serotonin and noradrenaline  It takes about seven to 10 days for antidepressants to take effect

13. 13 Using the STEPS Approach 1. TCAs - Tricyclic Antidepressants Safety - unsafe in overdose cases Tolerability- side-effects numerous Efficacy- good to very good results Price- greatest advantage; inexpensive Simplicity- need 3x a day dosing

14. 14 Using the STEPS Approach 2. SSRIs - Selective Serotonin Reuptake Inhibitors (drugs of choice) Safety- no problem even in overdose Tolerability- mainly GIT, mild/transient Efficacy- good/very good Price- most are pricey; some are not Simplicity- once a day enough

15. 15 Using the STEPS Approach 3. SNRIs (Serotonergic and Noradrenergic Reuptake Inhibitors) NaSSA (Noradrenergic and Specific Serotonergic Antidepressant ) Safety- same as SSRIs Tolerability- NaSSA better than SNRIs Efficacy- same as SSRIs; NaSSA earlier (?) Price- more expensive than SSRIs Simplicity- both SNRIs & NaSSA 1x/day

16. 16 USUAL DOSES OF ANTIDEPRESSANTS TCAs Tofranil- 75-150mg/day; maintenance 75mg/day Surmontil- 75-125mg/day; maintenance 75mg/day SSRIs Zoloft or Serenata- 50mg/day; maintenance as is Prozac or Adepssir- 20mg/day; as is Lupram or Feliz– 20mg/day; as is SNRIs and NaSSA Cymbalta- 60mg/day; as is Remeron- 30mg/day; as is

17. 17 RESPONSE TO TREATMENT 70% - improvement with remission, on drug treatment alone 30% - no improvement; combination Rx needed 85% - improvement with antidepressants combined with psychotherapy 90% - improvement with antidepressants + ECT (selectively for the actively suicidal)

18. 18 DURATION OF DRUG TREATMENT Varies from 6 months to 3 years First episode usually for 6 months Repeat episodes at least 1-2 years Recurrent attacks (more than 5) about 3 - 5 years or longer Chronically depressed patients with suicidal attempts + a family history of depression or suicide may need indefinite treatment Problems of drug adherence a major worry

19. 19 SPECIAL PATIENT POPULATIONS Pregnant Patients 70% - report depressive symptoms 20% - postpartum depression Use of antidepressants during pregnancy reserved for the severely depressed For the post-partum, may give antidepressants but no breast feeding

20. 20 SPECIAL PATIENT POPULATIONS Children / Adolescents No approved antidepressants for patients < 18 years old (exception: Tofranil for enuresis) Lower doses are given, if at all (off label use) Psychotherapy preferred

21. 21 SPECIAL PATIENT POPULATIONS Geriatric patients High risk of suicide ( in patients with chronic, painful, debilitating co-morbid medical disorders) Rule of thumb: start low, go slow

22. 22 Pharmacoeconomics of Antidepressants (Mercury Drug February 2009) Tricyclic Antidepressants (TCAs) Tofranil 25mg – P14.00 x 3-4 Surmontil 25mg – P16.60 x 3-4

23. 23 Pharmacoeconomics of Antidepressants (Mercury Drug February 2009) Selective Serotonin Reuptake Inhibitors (SSRIs) Zoloft 50 mg – P119.50 *Serenata 50 mg – P59.00 Prozac 20 mg - P123.50 *Adepssir 20 mg – P43.75 Lupram 20 mg – P127.75 *Feliz 20 mg – P51.00 * bioequivalent

24. 24 Pharmacoeconomics of Antidepressants (Mercury Drug February 2009) SNRIs and NaSSA Cymbalta 60 mg – P196.75 Remeron 30 mg – P112.75

25. 25 Anxiolytics for Depression? Common choice among primary care physicians, e.g. benzodiazepines Unfortunately, not effective; may also cause dependence Remember: antidepressants can be effectively and safely used for both depression and anxiety; anxiolytics are only effective in anxiety disorders.

26. 26 Antidepressant combined with Anxiolytic? A good strategy. Rationale: Antidepressants take 7-10 days to take effect, anxiolytics almost immediately. For example: may give Serenata 50 mg/day with Altrox (brand of alprazolam) 500 mcg/day. After 10-14 days, stop Altrox and keep patient on Serenata.

27. 27 Anxiolytic with Antidepressant  Many depressed patients are also anxious (60%)  It’s important to control the anxiety symptoms early which are more disabling than depressive symptoms  Anxiolytics effect control quickly; antidepressants take time  Early control strengthens adherence

28. 28 SUMMARY The LAPEL method is a quick, highly sensitive, and highly specific way to detect major depression The STEPS approach shows that antidepressants like SSRIs are safe, tolerable, effective, priced reasonably, and simple to give (drugs of choice) Antidepressants combined with psychotherapy give best results ALWAYS ask about suicidal ideas/attempts

29. THANK YOU VERY MUCH INDEED! NOW, SMILE AND FIX YOUR LAPEL