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Pharmaceutical care of people with depression

Pharmaceutical Care of
People with Depression
Provide an overview of the diagnosis and therapeutic
management of depression

Identify key pharmaceutical care needs of
this group of patients

Explore ways of positively impacting on
the care of this patient population

Key aims:
Raise awareness and promoting mental
health and well-being
Eliminate stigma and discrimination
Prevent suicide
Promote and support recovery
Key Facts & Figures
• Life-time Prevalence: 1 in 2 women; 1 in 4 men• 30% of above with Major Depressive Illness• >80% treated in primary care• 50-60% of patients respond to 1st line Treatment• 25-30% placebo response in controlled trials• 20-60% of patients respond to switching between • 37% of patients relapse within 1 yr. of remission Depression - Diagnosis by DSM-IV
At least five of the following symptoms (including either 1 or 2)for two weeks and causing clinically significant distress orimpairment in functioning – 1. Depressed mood2. Loss of interest or pleasure in almost all activities • Significant weight loss or gain, or change in appetite nearly • Insomnia or hypersomnia• Psychomotor agitation or retardation (observable by others)• Fatigue or loss of energy• Feelings of worthlessness or excessive or inappropriate guilt• Diminished ability to think or concentrate, or indecisiveness• Recurrent thoughts of death or suicide Depression - At Risk Patients
• Adverse social circumstances• Drug and alcohol misuse• Physical illness• Hospitalised patients• Patients Rx musculoskeletal/CNS drugs• Postnatal women• Family h/o Depression Action:
refer cases of suspected undiagnosed depression

Options (alone or in combination)
• Psychotherapy
• Drug therapy
• Electro-Convulsive Therapy
Aims of treatment
• Remission of symptoms to the pre-morbid state
• Restoration of social and working capacity
• Reduced risk of relapse and recurrence
• Prevent suicide
Choice of Antidepressant
“There are no clinically significant
differences in efficacy between TCAs
and SSRIs.”
Geddes JR, Freemantle N et al
SSRIs versus other antidepressants for
The Cochrane Library , Issue No4, 2000Oxford: update Software (Cochrane review) Factors Influencing Choice
• Prominent features of depression• Co-existing disease states• Interacting drugs• Previous response to therapy• Individual tolerability to side effects• Ability to comply – one daily dosing may be simpler• Age of patient• Risk of overdose• Pregnancy & breast feeding - Generally SSRI 1st line but not indicated in mild

• Pre-synaptic Receptors• Transmission• Post-synaptic Receptors Tricyclic Antidepressants (TCAs)
• All act on Serotonin and NA but in differentproportions• Also hit muscarinic, histamine receptors – responsible for side effects • Some more toxic in overdose than others• Reserved for 3rd – 4th line these days Selective Serotonin Re-uptake
Inhibitors (SSRIs)
Serotonergic side effects• GI – Nausea, vomiting, dyspepsia• Central – dizziness, agitation, insomnia, headache• Others – Dry mouth, sexual dysfunction, bleedingdisorders, anorexia or weight loss.
Usually 1st line agents
Useful for patients with physical problems as have
good side effect profile
Monoamine Oxidase Inhibitors
Boost available monoamines by inhibiting breakdown by
monoamine oxidase enzyme (centrally & peripherally)

1. Irriversible inhibitors - Phenelzine, tranylcypromine,

Consumption of tyramine rich foods or sympathomimetic agents results in hypertensive crisis –dietary restrictions apply• Must not be prescribed with other antidepressants – washout Reserved as 4th-5th line but useful in phobic patients or
those with atypical hypochondriacal or hysterical features

2. Reversible inhibitors – Moclobemide

Venlafaxine & Duloxetine
Boost serotonin & NA levels by reuptake mechanism
• New monitoring guidelines for venlafaxine – baseline ECG andblood pressure. Not to be used if cardiac risk factors present.
ECG & BP monitoring on therapy.
• Some evidence to support high doses (225mg) in treatmentresistant depression. Still used in secondary care. Associatedwith raised BP.
• Side effects include nausea, insomnia, agitation, restlessness,ECG changes, hypertension, withdrawal effects (even withmissed doses) • Duloxetine does not have the same monitoring requirements butnot much experience with it yet Mirtazapine (NaSSA)
Noradrenergic and specific serotonergic antidepressant
2 antagonist – increases NA and serotonin levels centrally but post synaptically blocks 5HT2 and5HT3 subtypes so there is a specific action on 5HT1. Lesssleep disturbance and less sexual dysfunction• Also histaminergic – responsible for sedation and weightgain• Practically no anticholinergic effects and no cardiovasculareffects• Rarely blood dyscrasias General Risks of Antidepressant
• All antidepressants can cause hyponatraemia (CSMwarning)• All lower seizure threshold to some extent.
• All can cause sweating• All can cause “switching” in bipolar patients• Discontinuation reactions can occur with allantidepressants, but are more common in short half lifeagents regardless of class.
• Combinations of antidepressants are potentially risky andshould be used only under specialist supervision.
• Switching drugs should be carried out with care.
• Inadequate info provided by dr and pharmacist• Person’s ability to absorb and retain info can be affected adversely • Denial of illness• Stigma• Lack of efficacy• Presence or fear of adverse effects• Fear of addiction• Improvement in mood• Lack of awareness of the need for maintenance therapy Evidence shows that info provided in small chunks and reinforced over tme is an effective way to help improve retention of info and therapeutic outcome.
The Role of the Pharmacist
• Reduce stigma by using a responsive pro-active • Be responsive to possibility of undiagnosed • Provide information about antidepressants• Promote concordance• Monitor and provide support to patient & carers• Identify adverse effects and interactions • Discourage self diagnosis and treatment• Support people at risk of suicide Initial Prescription for
• Reduce stigma - reassure patient depression is a common
illness and most patients recover
• Emphasise lag period – side effects often present before
benefit, encourage to persevere.
• Discuss discontinuation reactions but reassure that medication
is not addictive
. Do not stop abruptly.
• For SSRIs ensure GP has discussed side effects – patient
should report any increase in suicidal thoughts or increase in
agitation or anxiety (may be indicative of akathisia). Discuss
common side effects of any antidepressant. Speak with the doctor.
• Ensure patient is aware of expected duration of treatment.
Result : Improved concordance, reduced potential for relapse.
Lack of Response/Switching
• Ensure adequate trial. Where some response a dose increasemay be considered.
• Usually switch to a different class is indicated, but can switchwithin a class in certain circumstances Switching guidelines –
• In theory it is better to stop and washout one drug before
starting another (must do this with MAOIs)
• In practical terms this is rarely possible if patient is ill.
• Potential problems with cross tapering include – antidepressant
discontinuation effects, interactions between the 2 drugs e.g.
some SSRIs increase TCA levels, serotonin syndrome
(potentially life threatening), cholinergic effects.
Stopping antidepressants
If stopped abruptly discontinuation symptoms may
include –

Headaches, restlessness GI symptoms, flu like symptoms, abdominal cramps, sleep disturbance, anxiety, agitation“electric shock” sensations (particularly with SSRIs)• Common with short half life drugs, rare with fluoxetine To avoid problems –

After < 8 weeks treatment withdraw over 1-2 weeks After 6-8 months treatment taper over 6-8 weeks After long term maintenance, reduce dose by 25% every 4 - How to Identify and Meet the
Pharmaceutical Care Needs
• Education checklist for first presentation or • Pharmaceutical care needs assessment for depression to identify gaps in patient knowledge, effectiveness, safety and compliance • What medication do you take for depression, what dose and when • How long have you been taking this treatment?• Do you know what to do if you miss a dose?• Has your medication made you feel better?• Do you think it is ok to stop your medication suddenly?• Are you sleeping well?• Do you check with a pharmacist before buying medicines including herbal and homeopathic medicines? Are you taking any other medicines, prescribed or bought? • What side effects, if any, do you think you are experiencing from • Do you ever forget or choose not to take your medication? “It mo easy fu see dem (pharmacist), and “The pharmacist can provide information and advice that we might not get from the doctor, and they can also pick up mistakes in the prescription. They really know about



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