Depressive Disorders Management PDF

DEPRESSIVE DISORDERS MANAGEMENT Dr. Sanjay Rao, MBBS, MD, FRCPsych, FRCPC, MBA Medical Director, Centre for Mental and Psychological Health & Unified CBT Academy Associate Professor of Psychiatry, Ottawa University and Additional Professor of Psychiatry, Dalhousie University THIS PRESENTATION Based...

DEPRESSIVE DISORDERS MANAGEMENT Dr. Sanjay Rao, MBBS, MD, FRCPsych, FRCPC, MBA Medical Director, Centre for Mental and Psychological Health & Unified CBT Academy Associate Professor of Psychiatry, Ottawa University and Additional Professor of Psychiatry, Dalhousie University THIS PRESENTATION Based on previous years feedback this will focus on CANMAT Guidelines Due to constraints of time, the advances in depression management/critical review of literature will be limited to those in the CANMAT recommendations. Specifics of basic psychopharmacology relevant to depression will not be covered (refer to psychopharmacology lectures). Specifics of psychotherapeutic approach will not be covered as there are separate lectures on this. However, knowing specific model for depression treatment makes a difference in achieving good outcomes in clinical practice.  FEW THINGS ABOUT THE 2023/2024 CANMAT UPDATE Questions and answers pattern One paper covering the key areas on general treatment of depressive disorders For special populations CANMAT 2016 is the still the resource Refer to the tables for the clinical exams The text of the paper has materials for MCQ for the Psychiatry Fellowship exams especially as it is very recent. Neuroscience based nomenclature (NBN) used for medications e.g serotonin-dopamine activity regulator instead of atypical antipsychotics  CANMAT GUIDELINES READING TIPS The recommendation may not align with the level of evidence (for e.g medication with unfavorable metabolic profiles like Olanzapine In the text look out for the with level 1 evidence level of evidence visuals is downgraded to second line)  RISK FACTORS FOR MDD Dynamic risk factors: Useful for formulation Can used for a personalized treatment planning treatments Static risk factors: Useful for formulation Longer term treatment planning SCREENING Recommended for individuals with depression risk factors in primary and secondary care settings. Validated scales should be used for screening, and sufficient resources and systems must be available for diagnostic assessment and treatment following positive screening results. Depression screening is most valuable in contexts where subsequent care pathways are clearly established.  SCREENING TOOLS 1. Screening Procedure: Use the PHQ-2 as an initial screener. If positive (score ≥2), follow up with the PHQ-9 to confirm and assess symptom severity. This two-step process improves specificity without compromising sensitivity compared to using the PHQ-9 alone. 2. Utility in Measurement-Based Care (MBC): PHQ tools are recommended for ongoing monitoring during treatment to track symptom progression and treatment outcomes. 3. Limitation: False positives so clinical interview is needed to confirm.  ASSESSMENT AND DIAGNOSIS Clinical Assessment musc incorporate diagnostic frameworks such as DSM-5 or ICD- 11 Assess vulnerability and resilience factors across the lifespan Collateral information Cultural sensitivity Explore childhood maltreatment and trauma Differential diagnosis and co-morbidity Medical workup: CBC and TSH More specific tests: Medical co-morbidity e.g cardiac (ECG) or late life depression (neuroimaging) USING DSM-5 TR SPECIFIERS Mainly descriptive and perhaps helpful in overall formulation Does not guide medication treatment (except psychotic and seasonal features) PDD category has MDD, dysthymia and residual symptoms. Focus could be on improving QOL, functional improvement. SUMMARY OF GOOD PRACTICE  EQUITY AND DIVERSITY 1. Higher Prevalence in Equity-Deserving Groups: 2. Barriers to Access: geography, language, beliefs, mistrust, stigma, underdeveloped, fragmented healthcare. 3. Strategies to Improve Access: Screening Programs Culturally Competent Care Collaborative Care Digital Health Interventions (DHIs) with cultural adaptations.  OBJECTIVES AND PHASES OF TREATMENT Goals Treatment Phases Primary Goals: Acute Phase: Symptomatic remission, full Duration: Approximately 8–16 functioning and quality of life, weeks or until symptom remission patient safety, relapse prevention Maintenance Phase: Individualized Goals: Duration: 6–24 months following the acute phase, or longer if Patient-centered approach & clinically indicated. shared decision-making (SDM) TREATMENT PHASES: ACUTE Objectives: Address patient safety (e.g., assessing suicide and other risks). Improve symptom severity and functioning. Achieve symptom remission (defined as resolution or near- resolution of symptoms using validated scales). Actions: Develop a safety plan. Use psychoeducation and self-management strategies (e.g., behavioral activation, problem-solving, and lifestyle changes). Implement evidence-based treatments and monitor treatment adherence and side effects. TREATMENT PHASES: MAINTENANCE Objectives: Maintain symptomatic remission. Restore functioning and quality of life to premorbid levels. Prevent recurrence. Actions: Monitor for residual symptoms and long-term side effects. Use psychoeducation to identify early signs of relapse and promote early intervention. Address barriers to care. Implement interventions that build resilience. Discontinue treatments when clinically indicated using evidence-based approaches.  SYMPTOM REMISSION Symptom remission=lower risk of relapse Non-Remission=Poor functional outcomes Remission + functional outcomes= Patient centred care Residual Symptoms common even with remission= risk of recurrence Chronic and Treatment-Resistant Cases may need focus on QOL and functional outcomes SUICIDE: MODIFIABLE RISK FACTOS SAFETY PLANNING ANTIDEPRESSANTS AND SUICIDE RISK 1. General Evidence on Risk Reduction: Reduce risk particularly suicidal thoughts. 2. Age-Specific Risk Variation: Young Adults (65 years): Reduced suicidal behavior. 3. Temporal Relationship with Risk: The month before antidepressants: Preeexisting risk from depression itself. The month after starting antidepressants: Activation symptoms. Discontinuing antidepressants: increases risk shortly after it. 4. Medication-Specific Considerations: SSRIs and SNRIs are commonly implicated. 5. Suicide risk monitoring Especially during the initial weeks of treatment  SHARED DECISION MAKING Importance of Shared Decision-Making (SDM) = Psychoeducation and therapeutic alliance. SDM improves satisfaction with care. (document SDM and Psychoed in your notes) Educational Component: oPharmacotherapy. oPsychotherapy. oNeuromodulation treatments. oLifestyle changes and self-management. oComplementary and alternative medicine (CAM). Clear explanations about how treatments work, and efforts to dispel myths or stigma (e.g., around medication or stress-related causes) are critical. SHARED DECISION MAKING: TOOLS Guidance Tools: CHOICE-D for patient and families (but too big a document for a single bite) My suggestions: Create high level summaries from this Use other resources e.g. NICE UK or Patient info site by credible associations. Think ‘educational principles’, use as a motivational tool, show optimism and expertise which shows choices (rather than expert opinions) History taking is a good place to assess treatment beliefs SHARED DECISION MAKING: OTHER CONCERNS What is available: e.g neuromodulation is not available Collaborative and integrative care: Care plan with more than one modality (e.g medications and psychotherapy) Cost of care: Medications/Psychotherapy My comments: Explore what you can offer Keep to the evidence base Explore resources Consider other advice: e.g employment, financial, legal, educational etc LIFESTYLE INTERVENTIONS Care Model Definition Key Features Advantages Challenges Stepped Care Sequentially escalating - Begins with the least - Efficient use of - May delay access to interventions based on intensive effective resources intensive treatments patient response and treatment - Focused on patient needed for severe severity - Adjusts care intensity needs conditions as necessary Stratified Care Tailors treatment to the - Personalized treatment - Direct and appropriate - Requires accurate patient’s severity and from the start treatment for severity initial assessment of complexity at the outset - Reduces unnecessary - Cost-effective for severity and complexity steps resource utilization Collaborative Multidisciplinary team - Involves primary care, - Comprehensive care - Relies on strong team approach integrating mental health - Reduces symptoms and coordination and Care primary care and mental specialists, and case suicidal ideation communication health managers - Especially effective for - May require more - Focus on underserved comorbidities resources and populations infrastructure  MEASUREMENT BASED CARE: PRINCIPLES 1. Definition: Routine outcome measurement and feedback to guide clinical decisions. 2. Core Components: Regularly administering validated outcome scales & during/close to patient encounters. Reviewing scale scores with patients. Using these scores along with clinical assessments to support collaborative decision- making. 3. Benefits: MBC improves medication adherence and treatment outcomes. Enhances the therapeutic alliance. Facilitates shared decision-making. More likely to detect suicidal ideation.  MEASUREMENT BASED CARE: APPLICATION 1. Application Across Modalities: Pharmacological treatments and psychotherapies. Identifies non-responders and change strategies. 2. Scales Used in MBC: Validated scales for symptoms, side effects, functioning, and quality of life. Patient-rated scales (PROMs) are practical. Clinician rated scales can be added to PROMS 3. Using Scales Like lab tests scales are in context of the clinical assessment. Explore discrepancies and get more insights. Does not replace clinical interviews. MEASUREMENT BASED CARE: REFLECTIONS How Why is it not happening 1. Experiment and use it in close to 1. Models of clinical practice not 99% of your contacts ( reduces seen experienced during overestimation of improvement training. bias). 2. NONE of big EMRs are 2. Online/automated systems adequate mental health MBC. needed. 3. Can become mechanical MBC EXAMPLES TREATMENT CHOICES: STRATIFIED CARE COMBINING MEDICATIONS & EVIDENCE BASED THERAPIES WHY HOW 1. Enhanced Efficacy for Acute 1. Planned Sequential Treatment for Treatment: High-Risk Patients 2. Reduced Risk of Recurrence 2. Combined Treatment for Severe 3. Psychological Treatment for Residual Cases Symptoms 3. Life-Threatening Situations 4. Sustained Recovery FIRST LINE AND LEVEL 1 EVIDENCE SHOULD BE CHOSEN FIRST 12-16 sessions with first line treatment is recommended (elsewhere up to 20 sessions recommended) Twice per week has better outcome  FIRST LINE AND LEVEL: ANTIDEPRESSANTS Medincation Mechanism Citalopram, Escitalopram,Fluoxetine, Fluvoxamine, SSRI Paroxetine, Sertraline Desvenlafaxine, Duloxetine, Levomilnacipran, Venlafaxine- SNRI XR , Milnacipran Bupropion NDRI Mirtazapine Alpha-2 Antagonist; Serotonin 2 (5-HT2) Antagonist Vilazodone Serotonin Reuptake Inhibitor (SRI); 5-HT1A Partial Agonist Vortioxetine Serotonin Reuptake Inhibitor (SRI); Multi-modal Serotonin Receptor Modulator Agomelatine Melatonin Receptor Agonist (MT1/MT2); Serotonin 2 (5-HT2) Antagonist Mianserin Alpha-2 Antagonist; Serotonin 2 (5-HT2) Antagonist  SECOND LINE ANTIDEPRESSANTS Medication Mechanism of Action Amitriptyline, Clomipramine,Desipramine , TCA Doxepin ,Imipramine ,Nortriptyline, Protriptyline ,Trimipramine All Level 1 Moclobemide RIMA evidence Trazodone ( SRI; 5-HT2 Antagonist except Dex- Bup (Level 2) Quetiapine Dopamine, Serotonin, Alpha-1 and Alpha-2 Receptor Antagonist; Norepinephrine Reuptake Inhibitor Dextromethorphan-Bupropion – NMDA Antagonist; (NDRI); Sigma-1 Receptor Agonist Nefazodone (SRI); 5-HT2 Antagonist Selegiline Transdermal Selective MAO-B Inhibitor THIRD LINE ANTIDEPRESSANTS: LEVEL 1 EVIDENCE Medication Mechanism of Action Phenelzine MAOI Tranylcypromine MAOI Reboxetine NRI  INITIAL SELECTION OF MEDICATIONS Personalisation Efficacy, Potential adverse effects, Clinical presentation, Cost considerations, Patient prefere Psychoeducation for Patients Adverse Effects Management SSRIs and SNRIs often have gastrointestinal-related side effects. Comparative ratings of medications include sedation, weight gain, and sexual dysfunction risk Clinical Factors in Selection: Comorbidities, patient age, and symptom dimensions (e.g., cognitive dysfunction or anxiety) may Specific recommendations: -Elderly Patients: SNRIs like duloxetine may be more effective. -Young Patients (