This webinar was sponsored by Dr. Reddy’s. Dr Korb dived deep into antidepressants, the following is a summary, based on his talk.
***Click below to watch the full presentation and earn a CPD point
The lifetime risk for major depressive disorder (MDD) is 10% to 25% for women and 5% to 12% for men. Canadian annual prevalence rates for MDD are estimated in the range of 4.5% - 4.8%.
The rate of depression in females is two times that of males. The highest rates of depression are seen in women of reproductive age.
Cognitive symptoms may be more prominent in elderly MDD patients.
Cultural features can have significant influence on the experience and communication of depressive symptoms. In terms of genetic features, family history is associated with an increased risk of depression.
The average age of disease onset is in the mid-20s. Nearly two-thirds of MDD patients have multiple episodes. The risk of recurrence progressively increases with each successive episode and decreases as the duration of recovery increases.
Depression = ‘whole body illness’
Depression is a whole-body illness, as illustrated below.
Psychological = depressed/sad and /or irritable mood, low motivation,
reduced sexual desire, feelings of guilt failure and worthlessness,
loss of interest or pleasure, hopelessness or helplessness,
preoccupation with death and suicidal thoughts, illness as punishment.
Biological/ Physical = sleep disturbance, fatigue, constipation, changes in appetite, weight loss or gain, generalised aches and pains; poor concentration.
Social = social withdrawal, reduced interest in hobbies and leisure activities, poor performance at work/studies, difficulties in relationships, impaired role functioning.
Classes of antidepressants
The following classes of antidepressants are available:
- Tricyclic and tetracyclic antidepressants (TCAs) - imipramine, clomipramine
- Monoamine Oxidase Inhibitors (MAOIs + RIMAs) - tranylcypromine, moclobemide
- Selective serotonin reuptake inhibitors (SSRIs) - fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram, escitalopram
- Selective soradrenaline reuptake inhibitors (NRIs) - reboxetine
- Serotonin-noradrenaline reuptake inhibitors (SNRIs) - duloxetine,venlafaxine, desvenlafaxine
- Serotonin-2 antagonist and reuptake inhibitors (SARIs) - trazodone
- Noradrenergic and specific Serotonergic Antidepressants (NaSSA) - mirtazapine
- Dopamine and noradrenalin reuptake inhibitors (DNRI) - bupropion
- Melatonergic - agomelatine
- Multireceptor - vortioxetine.
Neurotransmitters and related symptoms
The following neurotransmitters deal with these symptoms:
Serotonin: Mood, anxiety, pain, sleep, guilt and worthlessness, appetite and weight, suicidality.
Noradrenaline: Interest, anxiety, hypersomnia, pain, concentration, fatigue, psychomotor retardation, appetite and weight.
Dopamine: Sexual dysfunction, hypersomnia, concentration, fatigue, psychomotor retardation, and anhedonia.
Consider and measure functional outcomes, QoL and treatment progress, and be aware of adverse effects of antidepressants.
To find out safety of medication during pregnancy and breastfeeding, go to: www.drugs.com/pregnancy
To find out about clinically relevant drug-drug interactions, go to https://reference.medscape.com/drug-interactionchecker
Questions that Dr Korb addresses in the webinar include:
- How long do you wait for a response from an antidepressant?
- How long do you continue an antidepressant?
- How do you manage inadequate response to an antidepressant?
Risk factors for depression treatment failure
Bear in mind that the following could be risk factors for treatment failure in depression:
- Co-existing medical illness
- Co-existing psychiatric illness
- Cognitive impairment
- Family history of treatment failure
- Genetic polymorphisms in serotonin transporter proteins
- History of physical or sexual abuse
- Inadequate medication dose
- Inadequate treatment duration
- Incorrect diagnosis
- Severity of depression
- Treatment non-adherence.
Pharmacological strategies for treatment-resistant depression (TRD)
Table 1 illustrates how to deal with TRD.
|Table 1: Pharmacological strategies for TRD
Increase the dose or duration or alter the timing of the primary antidepressant.
Stop first medication, start next one as monotherapy. New drug can be within or across class.
Add a second drug (adjunct) that is not an antidepressant to the antidepressant that has not produced and adequate response.
Two antidepressants used together, typically for synergistic mechanisms.
What novel treatments are being investigated?
There are non-pharmacologic treatment strategies for TRD.
Neuromodulation treatment of major depression:
- Electroconvulsive therapy (ECT)
- Repetitive transcranial magnetic stimulation (rTMS)
- Vagal Nerve Stimulation (VNS)
- Psychosurgery/ deep brain stimulation (DBS).
- Partial sleep deprivation
A comprehensive treatment approach includes:
- Psychotherapy (cognitive behavioural therapy and group therapy – family)
- Therapeutic goals
- Social support
- Life coaching
- Physical wellness
- Exercise and nutrition
- Self-help (bibliotherapy)
- Spiritual life
- Support group.
Death by suicide and psychiatric diagnosis
Psychological autopsy studies done in various countries from over almost 50 years report the same outcomes. Approximately 90% of people who die by suicide are suffering from one or more psychiatric disorders:
- Bipolar disorder, depressive phase
- Alcohol or substance abuse
- Personality disorders such as borderline personality disorder.
***Box: Warning signs of suicide
- Threatening to hurt or kill oneself or talking about wanting to hurt or kill oneself
- Looking for ways to kill oneself by seeking access to firearms, pills, or other means
- Talking or writing about death, dying, or suicide when these actions are out of the ordinary for the person
- Feeling hopeless
- Feeling rage or uncontrolled anger or seeking revenge
- Acting reckless or engaging in risk activities – seemingly without thinking
- Feeling trapped, like there’s no way out
- Increasing alcohol or drug use
- Withdrawing from friends, family and society
- Feeling anxious, agitated or unable to sleep or sleeping all the time
- Experiencing dramatic mood swings
- Seeing no reason for living or having no purpose in life.
Physician burnout and depression
Stress, anxiety and anger are at a high in 2022. Family medicine ranks in the top five of physicians that are the most burned out. First place is emergency medicine (60%), then critical care (56%), obstetrics and gynaecologists (53%), and infectious diseases tied with family medicine, both 51%.
If you as a healthcare worker need support, there is a 24-hour helpline available, by the Healthcare Workers Care Network. Call 0800 21 21 21, SMS 43001, or go to www.healthcareworkerscarenetwork.org.za.
You can contact Dr Kerb at email@example.com or go to www.sadag.co.za for additional resources.