Depression treatment

What is the stepped care model of depression treatment?

A structured approach that tailors interventions based on symptom severity and patient response.

What are the steps of the stepped care model?

- Step 1, mild symptoms

- Step 2, mild to moderate depression

- Step 3, moderate to severe depression

- Step 4, severe and complex depression

Describe the treatment for step 1.

- Assessment of symptoms

- Psycho-education

- Active monitoring

- Onward referral for further assessment and intervention

Describe the treatment for step 2.

- Low-intensity psychological or psychsocial interventions.

- Medication

- Onward referral

Describe the treatment for step 3.

- Medication

- High intensity psychological interventions.

- Combine treatments and collaborative care.

- Onward referral.

Describe the treatment for step 4.

- Medication

- High-intensity psychological intervention.

- Electroconvulsive therapy (ECT)

- Crisis service

- Combined treatments

- Multi-professional and inpatient care.

What are examples of low-intensity psychological interventions?

- Guided self-help

- Being active

- Computer based CBT

What are examples of high intensity psychological interventions?

- Psychological therapies

- CBT

- Interpersonal therapies

- Relaxation therapy

- Anxiety management

- Mindfulness related therapies and counselling.

What is the non-pharmacotherapy for subthreshold, mild, moderate and severe depression?

- Social support

- Low intensity psychological interventions.

What is the non-pharmacotherapy for severe and complex depression?

- High intensity psychological interventions

- Electroconvulsive therapy (ECT)

- Transcranial magnetic stimulation (TMS)

Who is considered for antidepressants (NICE CG90)?

- Past history of moderate-severe depression.

- Persistent sub threshold depressive symptoms for more than 2 years.

- Mild depression persists following other interventions.

How are antidepressants selected?

- Duration of episode

- Previous antidepressant response

- Likelihood of adherence

- Potential adverse effects

- Patient preference

How should antidepressants be prescribed?

- Start at a lower dose (half the standard) and increase to the target over a few days or weeks.

- Does not apply to mirtazapine or tricyclics.

What drugs are used in combination for depression?

- Lithium + Antipsychotic/antidepressant.

- Antipsychotic choice could be aripiprazole, onlanzapine, quetiapine or risperidone

- Can increase side effects and increase monitoring requirements.

What is first line depression treatment?

- SSRIs

- SNRIs

- Tricyclics

What is second line depression treatment?

- SSRIs

- Tricyclics

- MAO inhibitors

Why do SSRIs take time to show full antidepressant effects (delay)?

- Initially, increased serotonin triggers 5-HT1A autoreceptors on the presynaptic neurone, which act as a brake, reducing serotonin release.

- Over time (weeks), these autoreceptors desensitise and stop inhibiting serotonin release, allowing more serotonin to be available at the synapse.

Describe treatment of drepression in children.

- Fluoxetine (SSRI) is first line

- Sertraline (SSRI) or citalopram (SSRI) is second line.

How and when should antidepressants be used in people under 20?

- Positively exclude any possibility of bipolar depression.

- Counsel and be sure the family is aware of the possibility of suicide.

- Start slowly e.g., fluoxetine 10mg.

- Increase slowly as the person tolerates it.

Describe treatment of depression in pregnant women.

- Depression risk is higher during pregnancy, affecting bonding and self-care.

- Untreated depression is riskier than taking antidepressants.

- Some studies suggest a link between SSRIs and autism, but evidence is unclear.

- Paroxetine should be avoided due to risks (e.g., congenital heart defects).

- Limited evidence shows minimal impact of SSRIs on postnatal development.

Describe treatment of depression in the elderly.

- There are no ideal antidepressants.

- SSRIs better tolerated than tricyclics.

- Increased risk of hyponatraemia, postural hypotension, falls and haemorrhagic stroke with SSRIs.

- Start low go slow.

Describe treatment of depression in patients with cardiac diseases.

- SSRIs are recommeneded.

- Mirtazapine is also suitable.

- SSRIs can prevent MI.

- Sertraline is best post MI compared to other drugs.

- CBT may be ineffective post MI unless depression was present pre MI.

Describe the cardiovascular effects of antidepressants.

- Can increase QT interval e.g., SSRIs and TCAs.

- Citalopram is contraindicated in prolonged QT.

- Escitalopram is contraindicated in prolonged QT.

- Must monitor fully

What antidepressant is most commonly prescribed in liver impairment?

Paroxetine

What are side effects of SSRIs?

- Gastrointestinal upset (nausea, diarrhoea, indigestion)

- Headache

- Sleep disturbances (insomnia or drowsiness)

- Dry mouth

- Sweating

- Dizziness

What are examples of SSRIs?

Citalopram

Escitalopram

Fluoxetine

Fluvoxamine

Paroxetine

Sertraline

What are examples of TCAs?

Amitriptyline

Nortriptyline

Imipramine

What are examples of SNRIs?

Venlafaxine, duloxetine

How can citalopram tablets be converted to oral drops?

4 drops is equal to a 10mg tablet

4 drops = 10mg

Can SSRIs be taken with NSAIDs?

SSRI use roughly double the risk of upper GI bleeds, and this is increased to 3-fold by concurrent NSAIDs