THE PHILIPPINE COLLEGE OF PSYCHOPHARMACOLOGY

2008

MAJOR DEPRESSION(Featuring the LAPEL

method)

TEACHING MODULE FOR THE PRIMARY CARE PHYSICIANS

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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

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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

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• 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

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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)

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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

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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

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LAPEL QUESTIONSLow 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?”

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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?”

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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)

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MAJOR DEPRESSION

• Treatment Strategies (including the STEPS approach)

Antidepressants- TCAs, SSRIs, SNRIs / NaSSA

Psychotherapy

Electro-convulsive treatment (ECT)

Combination Rx

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ANTIDEPRESSANTS

The most important treatment Antidepressants increase levels of

serotonin and noradrenaline It takes about seven to 10 days for

antidepressants to take effect

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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

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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

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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

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USUAL DOSES OF ANTIDEPRESSANTS•

• TCAs Tofranil- 75-150mg/day; maintenance 75mg/day

Surmontil- 75-125mg/day; maintenance 75mg/day

• SSRIsZoloft or Serenata- 50mg/day; maintenance as isProzac 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

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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)

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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

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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

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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

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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

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Pharmacoeconomics of Antidepressants (Mercury Drug February 2009)

• Tricyclic Antidepressants (TCAs)

Tofranil 25mg – P14.00 x 3-4

Surmontil 25mg – P16.60 x 3-4

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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

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Pharmacoeconomics of Antidepressants (Mercury Drug February 2009)

• SNRIs and NaSSA

Cymbalta 60 mg – P196.75

Remeron 30 mg – P112.75

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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.

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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.

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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

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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

THANK YOU VERY MUCH INDEED!

NOW, SMILE AND FIX YOUR LAPEL