10 Minutes Clinical podcast on Depression

• Depression is the most common psychiatric disorder
• 80% of UK cases treated in primary care
• 5% of adults will have a depressive episode at some time
• More common in women, but men are at greater risk of suicide
• Primary care screening is helpful (such as PHQ-9)
• Clinician’s choice regarding whether investigations are required in each case
• When treating, review after two weeks (incl. telephone/video currently)
• For mild cases, CBT is the first-line treatment (availability/waiting time issues)
• If suicidal risk/ideation and/or under 30 review in one week.
• Ideally, review every 2-4 weeks for three months.
• If no improvement after one month, check compliance. If good, consider increasing the dose or changing Rx.
• If improving, continue for 6 months
• Mild cases have a high chance of spontaneous recovery.
• 10% of cases have persisting symptoms. Prognosis is worse in personality disorders/anxiety/psychosis features.
• The average depressive episode lasts 6/12. Recurrence risk increases with repeat episodes (50% after one).
• Consider antidepressants in mild cases if symptoms persist despite IAPT, especially in people with a previous history of worsening depression and/or symptoms present for more than 2 years
• In moderate or severe cases, use antidepressants + CBT and consider a psychiatric opinion (can include ECT)
• SSRIs are as effective as TCAs but with less risk of overdose and a better side effect profile. Look at what has worked previously, if applicable.
• The choice of an SSRI is usually the prescriber’s preference. Should be generic due to efficacy equivalence (but Cochrane review suggests escitalopram may be most effective, with the highest likelihood of remission).
• Remember that sertraline has fewer drug-drug interactions, so it can be considered in polypharmacy. Also, increased bleeding risk with SSRIs, so consider PPI if aspirin/NSAIDs are also being taken.
• Always explain the time to work (typically 2-3 weeks)
• When stopping, reduce gradually over 4-8 weeks and remember the long half-life of Fluoxetine – may be stopped more quickly
• Explain possible withdrawal symptoms and reassure if mild. If significant, add back and withdraw more gradually.

References and resources

• Overview | Depression in adults: recognition and management | Guidance | NICE
  Depression in adults – Symptoms, diagnosis and treatment | BMJ Best Practice
• Overview – Clinical depression – NHS (www.nhs.uk)