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Future Proofing
Reducing the Risk of Recurrent Depression
Rob Shieff
Disclosures
None
Depression – a diagnostic look
At least 2 weeks
Low mood Anhedonia
Sleep Appetite / Weight Fatigue Activity Self-worth Thoughts of death Thinking / Concentration / Decision making
Distress / Impairment
No other explanation
Low mood Anhedonia
Appetite
Insomnia
Fatigue Activity
Self-worth
Concentration
Suicide
Sexual problems
AnxietyVocationalProblems
Anger
Relationship problems
Pain and MUSD and A
The 5 Rs
Response, Remission, Recovery, Relapse and Recurrence
SEVERITY
Normal
Symptoms
Syndrome
TREATMENT PHASE
Acute Continuation Maintenance
16 weeks 12 months 12 months
Response
Remission
Relapse
Chronicity
Recovery
Recurrence
Presentation
PartialRemission
The Size of the Problem
New Zealand : Life-time prevalence = 16%
World wide : Prevalence varies widely
USA : 17 %
Japan : 3 %
Gender : Female : Male = 2 : 1
Risk for Depression Accumulates
Lifetime risk for First Episode = 16%
Risk for recurrence after 1 episode = 50%Risk for recurrence after 2 episodes = 65%Risk for recurrence after 3 episodes = 70%
Intensity of Recurrent Episodes Increases
What does this mean ?
Managing Depression is a Two Target Process
Treat the current episode
Make sure that this is
the last episode
The first step in preventing recurrence
Treat the current episode to REMISSION
Gone
or
Very few / Very mild
Symptoms Functioning
Normal
Why is Remission so important?
Partial response without remission is associated with :
Impaired Quality of Life
lower work productivity / worse social functioning
intensification of other psychiatric / physical health problems
greater health care use
higher suicide rate
• Higher Risk of Recurrence
Treatments won’t work if they’re not used
We can increase adherence by offering :
1. Support
2. Information
Realistically optimistic – probable benefit and time-frame
Accurate and specific – side-effects : type and management
Weeks
side-effects
benefit
Securing Remission
• Make it a shared goal
• Treat comprehensively
• Treat aggressively and tenaciously
• Target adherence
Game Breaking Side - effects
Weight gain
Sexual dysfunction
Fighting against weight gain
Patients can’t put on 10kg if you don’t let them put on 5kg
5
1. Dry mouth Calories in drinks Water or low calorie drinks
2. Calmer / less agitated Burn fewer calories Exercise
3. Hungrier / Lose the feeling of fullness 3 meals / smaller portions5 – 6 small meals / protein
Topiramate
4. Carbohydrate craving Low GI carbsLimit carbs after lunch
5. Metabolic shift MetforminGarcinia cambogia
Problems Solutions
Eat your breakfast yourself , share your lunch with your friends and give your dinner to your enemies.
Sexual Dysfunction
You won’t find out if you don’t ask
Symptoms of
Depression
Side – effects of Medication
Interest / Arousal / Orgasm
Offenders
/ Venlafaxine > TCAs > OthersSSRIs
Paroxetine > The Rest
Strategies
• Wait Wait Wait
• Reduce dose ( beware relapse )• Drug holiday ( beware withdrawal )
• Add : Sildenafil ( Men and Women )
BupropionMirtazapine
Ginkgo biloba
• Switch : BupropionMirtazapine
Duloxetine
Preventing Recurrence
Comprehensive Care
MEDICATION PSYCHOLOGY LIFE - STYLE
Managing Medication Into the Future
How much?
How long?
Carry on with whatever it took to get fully better
At least 6-9 months following recovery
Mood
Time
(months)
55%
20%
35%
The Case for Longer Term Treatment
Recurrent Depressions are likely to recur
Recurrence rates are higher with medication alone
Psychological / Life-style factors are protective
Extend treatment if : Multiply recurrent / Severe
Unable or unwilling to add other strategies to pills
New evidence may support life-long treatment in all cases
Depressions occur while on medication
RESILIENCE
Non-medication Approaches
Knowledge
Complementary Medicine
• St. John’s Wort ( Hypericum perforatum )
• Omega 3 Fatty Acids
• S – Adenosylmethionine ( SAMe)
• Inositol
• Resveratrol
• Magnesium
• Vitamin D
Manage Stress
Drugs and Alcohol
AlcoholIdeally : zero
Realistically : 2 – 3 Alcohol Free Days each week
3 – 4 standard units on drinking days
DrugsIdeally : zero
Realistically : depending on the drug - as low as negotiable
CaffeineIdeally : zero
33 units7 units
1.6 units
1.3 units
Life - style
Structure Balance
Activity Scheduling
C B T
Depression : The Lost Disorder
Loss of :
Interest
Energy
Joy
Confidence
Enthusiasm
Motivation
Concentration
Will
Purpose
WITHDRAWL
INACTIVITY
The Worse I Feel
The Less I Do
Consequences
If we stop doing the things that make us feel happy, we tend to stop feeling happy
“ I’ve got to stop these pills ….. they’re making me feel flat ”
We are what we do …… If we stop doing, we loose worth / valueThe less we do the more empty space we create in our livesWhen we do less, we tend to lose structure and balance in our lives
Antidepressants are anti-sad pills, they are not happy pills
Happiness is a by-product of what we do
Take one day at a time
Break the day into hourly blocks
Match activities to times
Model together, apply at home
Best done just before bed
Review today ~ plan tomorrow
Brighter mood
Ready for the morning
Tomorrow
6-7
7-8
8-9
9-10
10-11
11-12
12-1
1-2
2-3
3-4
4-5
5-6
6-7
7-8
8-9
9-10
10-11
The Process
Sleeping
Eating
Add in appointments
Plan for:
Exercise ( ~ 30 - 40 min )
and / or
Relaxation ( ~ 20 - 30 min )
Tomorrow
6-7
7-8
8-9
9-10
10-11
11-12
12-1
1-2
2-3
3-4
4-5
5-6
6-7
7-8
8-9
9-10
10-11
The BasicsThe Crucial Extras“Achievement” Activities
THINGS I NEED TO DO
Things you enjoy once they’re done
• Try to do 2 – 3 each day
• WORK
• Jobs or tasks from a “ To Do” List
Wake up
Go to Bed
Breakfast
Lunch
Dinner
Walk
Meditation
Load of Washing
Cooking
Do the Dishes
To Do List
Recurring Things :
• Cooking
• Cleaning
• Washing
• Shopping
One – Off Things :
• Sort the IRD
• Prune the roses
In bits
“Pleasant” Activities
THINGS I LIKE TO DO
Things you enjoy while you’re doing them
• Try to do 2 – 3 each day
• Harder to find :
“ What did you use to like to do ? ”
“ What do your friends like doing ? ”
“ What have you always wanted to do ? ”
Stroll around a big book shop
Coffee with Kate
Reading
Watch DVD with Paul
Go to the doctor
Sleep Hygiene
RoutineAfternoon exerciseEarlyish dinnerSupperHot shower / bathHerbal remediesDark and quietBed for sleep only
Manage Physical Health and Pain
Crucial Basic Psychological Strategies
A Stitch in Time
Early Warning Signs
Action Planning
Early Warning Signs
Onset of Depression is often a slippery slope
Future episodes tend to mimic past episodes
The earlier you spot it, the easier it is to stop it
Symptom profiles tend to be idiosyncratic
Help the patient identify their early signs of a slip
Remember that early changes are often more obvious to someone else
Make a list and use it as a reference
• shift of sleeping pattern
• irritability
• sense of humour goes
• singing in the shower stops
• misses gym sessions
Action Planning
If you know what to look out for
You keep your eyes open
You take action early
You are more likely to stay well
• Let other people know
• Look for precipitating stress and deal with it
• Keep active and busy
• Fight negative thoughts
• Be prepared to review medication options
A common problem with most therapies
The more you think about your thoughts and feelings, the worse you feel
A solution
A Therapy Wind-shift
anxiety
peace
Mindfulness Meditation
Acceptance and Commitment Therapy
( ACT)
misery
A couple of thoughts about thoughts
We all have negative thoughts from time to time
Is there a difference between :
I made a mess of that I made a mess of that
I don’t know why I bother
I never do anything right
No wonder no-one likes me
I made a mess of that
It’s not our thoughts and feelings that get us into trouble
It’s the way we think and feel about our thoughts and feelingsthat does the damage
Unless we’re careful, we tend to think our thoughts are facts
Re : Medication
Melbourne flight
Cateye PC
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Term 2 :
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FW: Registra
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Junk Thoughts
Thoughts to think about
Helpful
Un-helpful
Mindful inattention
Take action
Review and - if need be - take action
Sorting Thoughts
… that’s all from me
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