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Challenges in management of depression
Dual action drugs are more potent and there is a risk period
early on of suicide during treatment- Prof. Williams
TCAs particularly amitryptiline still have a place in primary care
Myocardial Infarction patients with depression have greater chance
of subsequent MI -Dr. Ashley Baldwin

COVENTRY (UK): Dr. Hamish McAllister Williams from New Castle, UK gave his presentation on “Challenges in management of depression” at the Midland Psychiatric Research Group annual meeting held from June 8-10^th 2006. This session was jointly chaired by Dr. Nil and Dr. Harish Gadhvi. He started his presentation by talking about challenges and controversies and referred to NICE guidelines No. 23.  Speaking about recognition of depression he mentioned about mild, moderate and severe depression and assessing severity of depression as per DSM-IV criteria. He also referred to British Association of Psychiatrists guidelines on depression.

Prof. Williams then talked about suicide behaviour of SSRIs, risks and monitoring of antidepressants with special reference to venlafaxine and its cardiotoxicity. He also gave details of various RCTs and depression and discussed in detail the selection of medication. Speaking about principles of selection he specially mentioned previous response with medication.  A question, he said, is often asked whether all antidepressants are equal in safety and efficacy. Various studies with SSRIs and TCAs, he said, have shown that there was no drop out in early stages with any of these medications. His conclusions were that there are several substances for the management of depression.  They do not increase the suicide rate. Dual action drugs are more potent than single action medications and there is a risk period early on of suicide during treatment.  Co-morbidity with depression, he said, is a major problem and with high dose one may get success. Continuing Prof. Williams said that in recent years there have been several controversies in management of depression. Anti-depressants, he pointed out, do work. More people using SSRIs get better as compared to TCAs but the TCAs particularly amitryptiline still have a place in primary care.

Bipolar disorders

His second presentation was on evolving guidelines on the management of bipolar disorders. He disclosed that NICE has finalized the second draft of its guidelines on bipolar disorders in February 2006.  These guidelines do not take away individual responsibility of healthcare professionals to make appropriate decisions in circumstances of individual patients. These guidelines emphasize on common aspects of care, psycho education providing information and collaborative working. Speaking about assessment, recognition and diagnosis, he laid emphasis on physical care. He opined that all these patients with bipolar disorders should be put on antipsychotic and then they should be carefully monitored. Use of valporate should be avoided in women under eighteen years of age or those with child bearing potential. As regards lamotrigene, be careful about its interaction with OCP?  Their initiation should be slow. The treating physicians should discuss contraception and pregnancy with women. Riseperidone works in acute resistant mania. Combination therapy gives better results in mania than monotherapy. In acute depression, taper off the antidepressants once the symptoms have reduced. In such a condition the first line of medication are the SSRIs and anti manic agents. In case of recent unstable mood, avoid the use of anti depressants.

Speaking about mood disorders and the risk of relapse Prof. Williams said that lithium does work in bipolar disorders. In long term carbamezapine is not as good as lithium. Study of medicine, he said is presented in two forms i.e. as Science and Art. Responding to questions during the discussion Prof. Williams remarked that we must prescribe with conviction as this is the art of psychopharmacology. Referring to the increased use of polypharmacy in United States, he opined that some patients may need polypharmacy and we should be careful about it. It should be used in selective cases. We do not know and we cannot predict which patient will respond to which drug. There is no logical scientific explanation for this, he added.

Understanding relative toxicity  of anti-depressants

Dr. Ashley Baldwin a noted psychogeritician was the next speaker in this session which was jointly chaired by Dr. Colin Campbell and Dr. Asaf Khan.  The topic of his presentation was “understanding relative toxicity of anti-depressants”. He started his presentation with a slide of disclosure wherein he accepted having received research grants from a large number of pharmaceutical companies. Depression, he said, is cardio-toxic. Speaking about platelet aggregation and smoking, he pointed out that depression is four times more common and greater in heart patients than general population. In heart patients depression increases the disease risk. Patients who suffer from myocardial infarction and also depression have greater chance of subsequent myocardial infarction. Depression symptoms are a risk and prognostic marker of cardiovascular disease and all cause mortality.  Major depression does raise cardiovascular mortality. Depression is also a risk factor for development and worsening of coronary heart disease. Cardio toxic effects are seen even in mild symptoms. Speaking about pathophysiology he said that there is a 30-40% risk of heritable depression. There is an increased risk of mortality and cardiac morbidity. SSRIs have beneficial effects on platelets and re-activity.

Dr. Baldwin then talked about stress and cardiovascular system, prevalence of depression in chronic cardiac disease patients and pointed out that cumulative mortality in depressed patients after myocardial infarction is greater than those who are not depressed. Depression does affect cardiovascular health. TCAs are associated with adverse cardiovascular effects. Similarly TCAs in IHD patients carry increased risk of cardiac morbidity. TCAs do improve symptoms of depression but have more side effects. One of the studies showed that 18% of patients were depressed after myocardial infarction and after three months, 14% of them died. Prognosis of untreated depression in elderly is extremely poor. Depression not only causes but also aggravates coronary artery disease and it also has increased morbidity and mortality.  SSRIs, he opined, were the safest antidepressants.

Speaking about Fatal Toxicity Index (FTI) he mentioned that TCAs has an FTI of 35 as compared to MAOIs 20 while venlafaxine has FTI score of just thirteen.  One may have to use different drugs for different patients. The new anti depressants, he stated, are used after first line drugs have failed to give desired results and patients have been prescribed other psychotropic. Most often these new anti depressants are prescribed by psychiatrists. The risk of suicide is more if there is a history of previous attempted suicide. Some patients may require more than one anti depressants. Venlafaxine is much safer as compared to other anti-depressants as regards likely suicide tendencies. TCAs, he stated, are very toxic for many reasons. They also have anti cholinergic effects. Their other side effects include seizures, confusion and tremor.

Venlafaxine, he further stated, has very little cardiotoxicity. There are no ECG changes with its normal clinical dose. These anti-depressants, he said, are not addictive and there is no diversion in life style. They also have no negative impact on family life. He concluded his presentation by saying that the fatal toxicity index vary over time and it is not just about toxicity and toxicity is not just about heart.  The risk of suicide is great during the first two weeks of therapy, he added.