CPG MDD

Summary
Introduction
• Mean time for recovery: 8 months
• Nearly 20% not recover after 2 years
• Majority improve with antidepressant

Prevalence
• Lifetime prevalence Malaysia: 5 – 17%
• 12% patient will progress to chronic unremitting course

Diagnosis
• DSM – 5

History taking
• Presenting symptoms
• Mode of onset
• Duration & severity of symptoms
• No. & severity of past episode
• Response to treatment
• Hospitalization
• Psychosocial stressor
• Family history
• Suicide attempt
• Past history of manic or hypomanic episode
• Substance abuse
• Medical illness
• Social history
• Social & occupational impairment

MSE
• To assess severity of depressive symptoms, present of psychotic symptoms, risk of harm to self &
others

Screening
Use 2 questions to screen for depression
(1) "During the past month, have you often been bothered by feeling down, depressed or hopeless?"
(2) "During the past month, have you often been bothered by having little interest or pleasure in doing
things?"

If patient answer “yes” proceed with further assessment

High risk group

• Physical health problem causing disability
• Past history of depression
• Family history of depression
• Other mental health problem
 • Substance abuse
• Dementia

Risk factor
• Loss of relationship
• Financial or occupational difficulty
• Poor social support
• Past suicide attempt
• Family history of suicide
• Alcohol abuse, dependence
• Other comorbidity
• Suicidal ideation
• Severe depression
• Psychomotor agitation
• Low self esteem
• Hopelessness

Criteria for referral to psychiatric service

• Unsure of diagnosis
• Suicide attempt
• Active suicidal plans
• Failure to respond to treatment
• Advice on further treatment
• Clinical deterioration
• Recurrent episode within 1 year
• Psychotic symptoms
• Severe agitation
• Self neglect

Criteria for admission

• Risk for harm to self
• Psychotic symptoms
• Inability to care for self
• Lack of impulse control
• Danger to others

Phase of treatment

Acute phase • Give anti-depressant until remission is achieved

Continuation phase • Continue treatment for 6 – 9 months for acute phase
Maintenance phase • Period to prevent recurrent
• Factor causing need for maintenance phase treatment
» Risk of recurrence
» Severe episode (suicide, psychotic feature, severe functional impairment)
» Side effect when continue treatment
» Patient preferences
Treatment for Major Depressive Disorder (MDD)

Pharmacological treatment

Acute phase treatment

Mild MDD
• Treating doctor may choose to start anti-depressant medication or not
• If patient have past history of moderate to severe depression who now present with mild depression,
start anti-depressant
• If patient are managed without medication, may be offered other way of managing depression
• Patient should be closely monitored & give follow up every 2 weeks
• If depression persist or worsen in the next visit, start anti-depressant

Moderate & Severe MDD

• Treating doctor must start anti-depressant medication
• 1st line anti-depressant: SSRI
• Next appointment should be within 2 weeks, unless clinical situation (suicide risk) makes an earlier
appointment necessary
• If the medication response is inadequate, plus no significant side effect, consider increase the dose
• If there is no response after 1 month of adequate dose of anti-depressant, switch to another
antidepressant
• If there is partial response, continue the same anti-depressant for another 2 weeks, if still partial
response, switch to another antidepressant
• If there’s need to switch to another antidepressant, choose single second antidepressant as
monotherapy is preferred compare to combination therapy – because of good compliance & cheaper
cost
• The second anti-depressant may be another SSRI or other anti-depressant class

Continuation phase
• Anti-depressant should be continue for at least 6 – 9 months after remission of depressive episode
• Anti-depressant dose used in acute phase should be the same for continuation phase

Discontinuation of pharmacotherapy
• Anti-depressant should be tapered down gradually over week (to avoid withdrawal symptoms) in
many cases, except in case of intolerable side effect

Maintenance phase
• After anti-depressant have been continued for 6 – 9 months after remission, proceed to maintenance
phase
• Factor must be consider:
» No. of episode
» Severity each episode
» Presence of residual depressive episode
» Ongoing psychosocial stressor
• Dose of anti-depressant for maintenance phase = dose used for previous acute treatment
• If patient have at least 2 recent depressive episode which cause significant functional impairment,
continue maintenance phase for at least 2 years
• If patient has high risk of recurrent, continue maintenance phase for > 5 years

Discontinuation of pharmacotherapy
• Anti-depressant should be tapered down gradually over week (to avoid withdrawal symptoms) in
many cases, except in case of intolerable side effect

MDD with Psychotic features

• Must combine anti-depressant with anti-psychotic
• Maintain anti-psychotic until full remission of psychotic symptoms

Role of benzodiazepine in depression

• Prescribe benzodiazepine as adjunct to anti-depressant if needed
• But must avoid giving benzodiazepine > 2 – 4 weeks

Failed response to initial treatment

• 30% depression patient not response adequately to treatment
• 15% depression patient develop chronic depression
• Non-responder = Patient who don’t respond after 4 weeks of anti-depressant therapy at adequate
dose

Reasons for treatment failure

• Incorrect diagnosis – ex failure to diagnose bipolar disorder
• Psychotic depression
• Medical illness – ex anemia, hypothyroidism
• Co-morbid psychiatric disorder – ex substance abuse or dependence, panic disorder, obsessive-
compulsive disorder, personality disorder
• Bad psychosocial factor
• Non or poor compliance

Strategies used to treat non-responder

• Optimization: Gradual increase dose, if there is no adequate respond, no significant side effect
• Switching: Changes anti-depressant from another same class or different class

Treatment Resistant Depression

• Failed to respond to 2 or more anti-depressant treatment at adequate dose for at least 4 weeks

Strategy to treat treatment resistant depression

• Switching: Changes anti-depressant from another same class or different class
• Augmentation:
» Lithium, give for minimum of 7 days achieving serum levels > 0.5 mEq/L
» Atypical anti-psychotic
• Combine therapy: Combine with another anti-depressant

ECT
Indication for ECT in patients with MDD
• Severe depression & functional impairment
• Psychotic symptoms
• Catatonic feature
• Life threatening condition – refuse to eat, suicide attempt & thought
• Acute treatment of moderate or severe depression
• To achieve rapid improvement of severe major depression ± psychotic features
• Treatment resistant depression

Psychotherapy

Mild MDD • Supportive therapy

• Problem-solving therapy
• Counselling
• Cognitive behavioral therapy
Moderate & severe MDD • Cognitive behavioral therapy
» Duration: 16 – 20 sessions over 6 – 9 months
Treatment resistant depression • • Cognitive behavioral therapy

Follow-up
Based on NICE guideline
• Patient should be seen again within 2 weeks of 1st visit
• If the patient is respond well to treatment, every 2 – 4 weeks in the 1st 3 months

Depression in elderly
Risk factor
• Old age
• Gender: Women

Why again associated with risk of depression ?

• Brain changes
• Vascular risk factor
• Cognitive impairment
• Physical illness & its disability causing
» Functional limitation
» Chronic pain
» Vision problem
» Medication use
• Major life events
• Stressor
• Financial strain
• Poor social support

Clinical features of MDD in elderly

• Psychomotor retardation
• Poor sleep
• Poor concentration
• Constipation
• Poor perceived health
• Prominent anxiety symptoms
• Cognitive deficits
• Prominent somatic symptoms

Treatment

Pharmacotherapy
• 60 -70% elderly show good response to standard treatment
• Treat with anti-depressant, dosage adjustment according to age
• 1st line anti-depressant: SSRI

Psychological
• Cognitive therapy
• Behavioral therapy
• Cognitive behavioral therapy
• Psychodynamic therapy
• Problem-solving therapy
• Exercise therapy
» Mild to moderate MDD