North West AUTUMN Conference Review - 20
NOVEMBER 2013 in MANCHESTER:
Depression – Treatments and Life Cycle
Lecture 1: Drug
Treatment: From first episode to refractory depression
Dr Peter Talbot, Senior Lecturer in
Molecular Neuro-imaging, University of Manchester
The day started with Dr
Talbot asking if antidepressants work. The answer was yes –
antidepressants are as effective as drugs for physical health and
the more severely ill a patient the greater the response. He
described the work of the specialist clinic (SAD – specialist
affective disorder) in Manchester where they conduct an initial
assessment to check that this is the correct diagnosis, assess
substance use, check for physical diseases, check for depressogenic
medication and exclude bipolar disorder.
Dr Talbot recommended a
stepped approach to moderate to severe depression:
Step 1 use SSRI e.g.
Sertraline - 50-100mg or Mirtazepine if need sedation for 4 weeks –
if no response
Step 2 try another SSRI
or SNRI e.g. Escitalopram, waste of time going to a high dose
Step 3 go to augmentation
– lots of research support for adding second generation
antipsychotics or lithium
In his conclusions Dr
Talbot stated that it was hard to predict outcomes, but clinicians
should aim for remission, instil hope, give individual medication
trials for 12 weeks maximum, have a stepped plan, use ECT and
psychology, for treatment resistance work through evidence based
treatment, refer to tertiary services and don’t forget
2: ECT are you still doing that?
Barnes, Consultant Old Age Psychiatrist, Merseycare NHS Foundation
Dr Barnes started by
describing how ECT began as an empirical treatment that has become
scientifically evaluated, that is safe with only 1 in 20,000 life
threatening incidents when used and has proven to be a most
The process involves an
induced modified fit plus muscle relaxant, anaesthetic and
monitoring. There has been a reduction in the use of ECT.
Does ECT work? Research
shows that ECT is effective and drugs plus ECT is better than ECT
or drugs alone. How does it work? The induced fit is needed for it
to work and increases monoamine receptor sensitivity, increases
monoamine receptor numbers, changes cerebral blood flow and changes
Dr Barnes suggested
discussing the options of unilateral (takes longer, more side
effects and less effective) and bilateral (quicker, more side
effects and more effective) with patients and recommended switching
to a different medication.
3: Mindful Based Treatments
Razzaque, Consultant Psychiatrist, North East London NHS Foundation
Dr Razzaque described
mindfulness as the non-judgemental awareness of the present moment;
an awareness of thinking and of observing thoughts. He described a
key correlation between experiential avoidance of unpleasant
emotions and mental illness.
We did a small
mindfulness exercise during the lecture. The use of mindfulness is
now recommended by NICE for depression and is being incorporated
into other psychological therapies. Mindfulness is a relaxed
awareness, a method for developing resilience. Dr Razzaque strongly
suggested that clinicians should use mindfulness themselves before
advising others. The approach needs cultivation like gardening,
incorporating into your day and for it to be practiced
Treatment Gap: Can we deliver psychological interventions to
British South Asians? Dr Nusrat Husain
This session enabled
participants to understand the need for cultural adaptation in
interventions to facilitate engagement and improve outcomes in
patients of British South Asian background as well as
recognise themes and adaptations in interventions that are specific
to South Asian culture and which impact on treatment when
interacting with patients from this community.
Therapy for Depression: Dr Sarah Knowles
Computerised CBT (cCBT)
is recommended by NICE for treating depression and anxiety.
However, there has been a lack of research into patient experience
of technologically-delivered therapy, and no independent trials of
effectiveness have been conducted in routine primary care. This
workshop discussed the results of the REEACT trial, the largest
independent trial of cCBT to date, including insights from
interviews with patients and professionals. Barriers to engagement
and implementation, and potential methods for improving patient
experience in the next generation of cCBT programmes, were
Trans-cranial Magnetic Stimulation have any noticeable effect?
Professor Peter Lepping
This session presented
results of a systematic review and meta-analysis answering the
question whether there is any clinical utility of Trans-cranial
Magnetic Stimulation, using a novel method to examine the clinical
relevance of the existing results from the literature.
The review concluded that TMS showed a modest advantage over
sham TMS for depression but not for treatment resistant
depression. The review also found that ECT was superior to
TMS in all comparisons.
4: Treating Adolescent Depression
Dubicka, Honorary Senior Lecturer in Child Psychiatry, University
of Manchester/Consultant Child and Adolescent Psychiatrist
Lancashire Care Foundation Trust
Dr Dubicka started by
reminding us that this was a complex comorbid condition with
increased suicidality and increasing levels of distress
particularly in girls.
recommended are multi-modal with SSRI’s and in particular
Fluoxetine first line treatment. Sertraline is the recommended
second line treatment and Escitalopram has increasing research data
to support its use. Paroxetine is contraindicated due to agitation
and hostility with tricyclics not recommended due to toxicity and
lack of evidence.
Dr Dubicka described the
role of CBT as useful for targeted cases such as patient choice,
comorbid anxiety or OCD. The CBT should be manualised specialist
care and treatment goals can include psychoeducation, optimism,
realistic expectations, emotional first aid and family work.
However there can be poor outcomes in adolescents due to
difficulties with motivation and engagement with homework.
Dr Dubicka recommended
managing insomnia by using melatonin, sleep hygiene, and addressing
lifestyle. She emphasised the importance of identifying and
treating depressed mothers.
Dr Dubicka also discussed
the risk of suicidality describing a consensus that fluoxetine is
the safest medication. She described more concerns about under
treatment and not over treatment and research evidence suggesting
that suicidality decreases once start any treatment.
5: Depression with Psychosis in EIP
Macmillan, Consultant Psychiatrist, South of Tyne EIP
Adolescence is a time of
increased mortality and morbidity because of increasing mental
illness, with mood disorders presenting commonly after puberty.
Patients presenting with depression with psychosis in follow-up
approximately 50% over 15 years go onto develop mania. Those with
recurrent depression are more likely to develop bipolar
Dr Macmillan suggested a
staging model as used for schizophrenia and this can be used as a
basis for planning treatment. At a lower stage use simpler
treatment, for a better prognosis, better response, and decreased
risk. US study found for those exposed to antidepressants more
seemed to develop mania than those not exposed to medication.
Recent research suggests
using a dietary intervention with the least healthy diet giving an
increased odds ratio of depression.
Dr Macmillan concluded
that prevention of depression was feasible and diagnosis and stage
of illness informed treatment options. Depression was a highly
recurrent illness with increasing disability that required early
use of best treatments and that antidepressants may worsen disease
course. The subjective report of hearing voices predicted the need
6: Self harm and recent findings from the Centre
of Suicide Prevention: Links with Suicide and
Dr Jayne Cooper,
Senior Research Fellow, Institute of Brain, Behaviour and Mental
Health, University of Manchester
Of completed suicides 9
out of 10 have a psychiatric disorder, 50-70% have depression. 15%
of depressed people die by suicide with a 20 fold increased risk of
The suicide centre has
been collecting data from 1997, they have found rates of suicide
decreasing but since 2008 rates have been increasing again. They
have found that females consistently more likely to self-harm but
male rates are increasing faster and closing the gap.
Kapur et al 2013 used the
study’s data to examine which treatment works with the main outcome
measure of repeat DSH. Psychosocial assessment some aspects work
e.g. opportunity to talk about problems, validation of distress,
key time to inspire hope and follow up needs to occur if promised.
Dr Cooper recommended holistic assessments including physical
health, self-care and medication with integration of mental and
Following up of the DSH
of 30,000 patients found approximately 300-400 killed themselves,
with suicide 20x more likely than the general population.
7: Depression in Older People
Dr Wendy Neil,
Consultant in Old Age Psychiatry Leeds and York Partnership
There is a relative lack
of data in the management of depression in later life especially in
over 80s. Research does show that cognitive impairment reduces
antidepressant efficacy. There are only 9 trials of
psychotherapeutic treatment, CBT shown to be effective. Dr Neil
recommended embedding therapy within a package of care. In
older people ECT improved remission, patients responded well with
no increase in side effects. There is no evidence of efficacy for
TMS, VNS, DBS in older people.
Recent meta-analyses have
shown that SSRIs, SNRIs are effective, Ciprani in 2009 recommended
Sertraline and possibly Escitalopram. Dr Neil recommended having a
sequenced plan with prolonged treatment (6-8 weeks) for refractory
depression and considering the use of augmenting or combining
drugs. She stated there was no evidence for use of larger doses and
advised caution in switching antidepressants.
She advocated maintenance
treatment as risk of recurrence was significantly greater on
discontinuation, with a NNT of 4 to prevent recurrence.
In conclusion Dr Neil
emphasised the importance of recognising depression, education,
embedding a psychological approach, monitoring symptoms and side
effects, and having a sequential plan with the next step
Conference Spring 2014 – Commissioning and service
Conference Autumn 2014 – Update on treating personality disorders
Academic Secretary, North West Division