CPD 37: DEPRESSION Biography - Paul Knox MPSI graduated in 2000 from Trinity College Dublin, and completed his pre-regristration in Unicare Pharmacy, Kilkenny. He the Managing Pharmacist of Cloughjordan Pharmacy from 2001-07 during which time he garnered a higher diploma (in community pharmacy) with distinction from TCD. Paul is currently completing a PhD from TCD, and recently appointed Managing Pharmacist of Coffeys Pharmacy in Roscrea.
Module 1 June 2012
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The exact depressive episode but an exact causal Sheehan et al reported cause of in 1996 that the estimated cost of relationship between a major life event and an to the Irish Health Services when added depression Depression, in pithy philosophical terms, is episode has for not patients been firmly established.pain The for 95 patients is one of the itcommonest reasons to seek is of unknown, essentially future withoutPain hope. Medically can theory should certainly not be discounted, to the amount Social Welfare payments received and 1 A recentand survey hasstresses shown that as many more with medical attention. but there be more difficult to define and equally difficult certain are associated the lost earnings of each patient amounted to 1.9 million to diagnose. It is the most the appears to be depression than others a) past or chronic as common 8.3 visits of per year to primary care physicians in –Ireland 6 affective disorders with a lifetime prevalence pounds at the time of referral. The recent data from PRIME a conventional stresses such as sexual abuse or poor parentwere due to symptoms of pain.2 A large scale survey carried of up to 15% with a six month prevalence of consensus child relationship; b) events which may affect survey show that the mean cost per chronic pain patient There is countries about 6% in the US sndout Europe. in 151,2European and Israel 2006, screening that a genetic a person’s selfinesteem such as the break up of is estimated at €5,665 per year across all grades of pain, significant disparity of incidence between the predisposition exists, a close or marriage; c) inferiority 46,394 respondents reported that relationship the prevalence of chronic sexes, with reports suggesting that women which was extrapolated €5.34 billion or 2.86% of Irish with a majortolife trauma complexes or feeling of not living up to their pain of moderate to severepotential intensity or in the adult Europeansofwas are twice as likely as men to suffer from the 7 preciptiating an depressive episode thus expectation others. GDP per year. This demonstrates an urgent need for cost 3can occur at any illness.3 Although depression 19%. leading to the biochemical changes often to manage chronic pain effectively. • Personality Factors – People with the effective strategies age, including infancy, it is estimated that the described in depressed patients. following personalities may be predisposed to average age of onset is in the late 20s, with More recent survey data from another study, carried out There are no universally accepted tests depression and at a higer risk of an episode the incidence and prevalence of depression in 2,019 pain and 1,472 primary that willchronic garner a positive Understanding pain confirmation than others: a) those associated with chronic women peaking in their in late 30s. people with chronic of depression in a patient. Various rating anxiety which may manifest care physicians across 15 European countries, have itself as irritability; AETIOLOGY OF DEPRESSION Chronic painscales is defined paindeveloped that outlasts haveasbeen thatnormal may healing b) chronic shyness associated with isolation demonstrated that chronic and painsocial affects 12-54% of the severity of a depressive avoidance; c) adult self-critics and time (usually demonstrate three to six months), and is most frequently The exact cause of depression is unknown, but Europeans, and its prevalence in with Ireland up worth; to 13%. The disorder, or help distinguish chronic those lowisself d)2perfectionism is there appears to be a conventional consensus associated with musculoskeletal disorders such as low anxiety from depression. Biochemical associated with longer episodes of depression. PRIME (Prevalence, Cost of Chronic Pain) study, that a genetic predisposition exists, with a ImpactInand its maladaptive form, perfecionism drives back pain and arthritis. it can also be associated tests, suchHowever, as the dexamethasone major life trauma preciptiating depressive on thean other hand, determined thetoprevalence of chronic people unattainable ideal, and their with other disorders suppression may proveora metabolic useful aid suchtests as depression episode thus leading to the biochemical subsequent to do so may often lead to pain to be as high as 35.5% in Ireland.4failure The PRIME study in diagnosis by some clinicians, but their changes often described in depressed patients. 6 or value neurologic conditions suchare asrarely multiple ; e)pain those who disorders enage long bouts of depression is limited, and thus, used. waswhich designed prevalence of chronic Below the common factors may to investigateinthe ‘self-focus’. Studies of rumination suggest sclerosis. contribute to depressioninare listed compare the psychological A formal diagnosis employing the ICD-10 Ireland; and physical health that self-focused attention is maladaptive and system requires at least four of the ten perpetuates depression. profiles those with and without chronic pain; and7 explore • Genetic factors – Although noofone major Pain (acute or chronic) can be categorised asthe nociceptive depressive symptoms, whereas DSM4 gene has yet been identified, heritability of pain-related disability. Responses to survey questions • Biochemical Factors – Thewere original or neuropathic. Nociceptive painfive is caused by nine an active IV requires at least out of the for a depression has been esitimated to range monoamine hypothesis suggested that illness, injury diagnosis of depression. obtained from 1,204 people. and/or inflammatory process associated with from 30-40%; a family history of depression depression was related to a deficiency in the accounts for 39% of the variance of depression Despite the advent of new antidepressant actual or potential tissue damage i.e. Nociceptive pain amount of cortical and limbic Despite of thea magnitude of the problem, chronic pain is serotonin (5in both sexes. Further evidence genetic drugs, the therapeutic effectiveness HT), noradrenaline (NA) and dopamine (DA); results from activity in neural pathways secondaryofto actual 2,5 link has been found in studies of children from andmost these agents has changed little since the both under-recognised undertreated in primary care. of the commonly used antidepressants or potential tissue damage. Nociceptive pain is mediated parents with depression who were adopted discovery of imipramine in the late 1950s. workreported by increasing or activity of Indeed, up to 38% of patients being levels inadequately by healthy patients. A higher incidence of located in skin, musculoskeletal system, these neurotransmitters.2 The concept ofby pain receptors A stepped-care approach may be the in primary care for their pain symptoms. In depression was found inmanaged the biological parents 8 noradrenergic and serotonergic forms ofbone, and joints. pain, oninthe most Neuropathic efficient, as outlined theother NICEhand, of adopted children withaddition, depression thanwith in the people chronic pain reported waiting upwidespread to depression has not gained support, guidelines. As pharmacists, we can sensory results from direct injury to a peripheral or central adoptive parents. little justification 2.2 years between seekingand helpthere and is diagnosis, and 1.9in measuring offer practical and emotional support to noradrenaline or serotonin metabolites innerve; the affected nerves do not produce transduction at 2 • Enviromental factors –years Enviornmental depressed patients. before their pain wasroutine adequately managed. 8 8 practice. nociceptors. Pain characteristics and associated conditions stresses can often be identified prior to a INTRODUCTION
for both types of pain are shown in Table 1. use by Healthcare Professionals in the Republic of Ireland only Learning, Evaluation,For Accredited, Readers, Network | www.learninpharmacy.ie © Copyright 2012 Pfizer Healthcare Ireland Date of Preparation: Module 1 June 2012 EPBU/2012/XXX
CPD 37: DEPRESSION
• Endocrine Factors – Depression is known to be associated with a number of hormonal abnormalities, including abnormalities in the hypothalamic-pituitary-adrenal axis, thyroid dysregulation and estrogen deficiency. There Module 1 is evidence linking increased cortisol levels with depression, thus used June as the2012 basis for the dexamethasone suppression test used in depression diagnosis.9
sionals Comordities in Ireland and medication factors – Disorders
of mood, particularly depression have been associated with several types of medication and a number of physical illnesses –
anagement inandprimary care Table 1 - Drugs physcical illnesses implicated in exacerbation of depression
ICD-10 CLASSIFICATION • Depressed mood, loss of interest and enjoyment • Reduced energy, increased fatigability and reduced activity • Marked tiredness with only slight effort • Decreased concentration and enjoyment • Reduced self-esteem and confidence • Feelings of guilt, shame and unworthiness • Bleak and pessimistic view of the future • Suicidal thoughts and acts of self harm • Disturbed sleep • Reduced appetite
DSM-IV CLASSIFICATION a) Depressed Mood b) Markedly decreased interest in all or almost all activities c) Significant weight loss or gain d) Insomnia or hypersomnia e) Psychomotor agitation/retardation f) Fatigue or loss of energy g) Feelings of worthlessness or excessive or inappropriate guilt h) Reduced ability to think or concentrate i) Recurrent thoughts of death, suicidal ideation, suicide attempt or specific suicide plan 2-4 of the symptoms must be present, comprising at least one of a) or b)
It is evident that central to both diagnostic paradigms is ‘depressed mood’ combined with a loss of pleasure in most activities. The severity of the disorder is determined by both the number and severity of the symptoms. A formal diagnosis employing the ICD-10 system requires at least four of the ten depressive symptoms, whereas the DSM-IV requires at least five out of the nine for a diagnosis of depression. Symptoms should be present for at least two weeks, with the patient suffering each affliction for most of the day. Both requiree at least one (DSM-IV) or two (ICD10) symptom of low mood to be present.11,12 The NICE guidelines favour the DSM-IV for its 2009 update as it is used in all the evidence reviewed and it provides definitions for atypical symptoms and seasonal depression.13
Moderate Depression – Symptoms or functional impairment are between ‘mild’ and ‘severe’. Severe Depression – The patient presents with most symptoms,a nd the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms. Dysthymia – subchronic minor depressive symptoms, relapsing and remitting for at least two years. This category, while often falling short of meeting the criteria required for a formal diagnosis, is important as it may cause considerable morbidity, human and economic cost, and may be a risk factor for a future major depressive episode.14 TREATMENT OF DEPRESSION
Analgesics Antidepressants Antihypertensive Anticonvulsants Opiate Withdrawal Amphetamine withdrawal Benzodiazepines and withdrawal Antipsychotics Ant parkinsonism agents Steroids Metoclopramide ehan et al reported in 1996 that the estimated cost of Propranolol n for 95 patients to the Irish Health Services when added Progestin-releasing contraceptives he amount of Social Welfare payments received and H-2 antagonists
lost earnings of each patient amounted to 1.9 million Malady nds at the time of referral.6 The recent data from PRIME vey show that the mean cost per chronic pain patient Viral Illness stimated at €5,665 per year across all grades of pain, Carcinoma ch was extrapolated €5.34 billion or 2.86% of Irish Neurological to disorders 7 P per year. This demonstrates an urgent need for cost Diabetes ctive strategies to manage Addison’s Disease chronic pain effectively. Systemic Lupus erythematosus Pernicious anemia
derstanding chronic pain
DIAGNOSIS AND CLASSIFICATION OF
onic painDEPRESSION is defined as pain that outlasts normal healing e (usually three to six months), and is most frequently There are no universally accepted tests that will ociated with musculoskeletal disordersofsuch as low garner a positive confirmation depression in aarthritis. patient. However, Various rating scales have been k pain and it can also be associated developed thatas may demonstrate the severity h other disorders such depression or metabolic of a depressive disorder, or help distinguish orders orchronic neurologic conditions such as multiple anxiety from depression. Biochemical rosis. tests, such as the dexamethasone suppression
tests may prove a useful aid in diagnosis by some clinicians, butcategorised their value isaslimited, and n (acute or chronic) can be nociceptive thus, are rarely used. In fact, evidence of a europathic. Nociceptive paininisacaused by anlead active chemical imbalance patient may to a precise diagnosis, e.g Addison’s disease ss, injurymore and/or inflammatory process associated with of hypothyroidism.10
ual or potential tissue damage i.e. Nociceptive pain NICE of 2009secondary touts two main ults from The activity in guidelines neural pathways to actual criteria used to identify and classify otential diagnostic tissue damage. Nociceptive pain is mediated depression: the Diagnostic and Statistical pain receptors in skin, musculoskeletal system, Manuallocated of Mental Disorders (now in its 4th year) 8 DSM-IV developed by theon American Psychiatric e, and joints. Neuropathic pain, the other hand, and the International Classification ults from Association; direct injury to a peripheral or central sensory of Diseases ICD-10 developed by WHO in 1992. ve; the affected nerves do not produce transduction at The diagnostic criteria outlined in the respective 8 are outlined (for those iceptors.classifications Pain characteristics and below associated conditions patients aged 18 and over) – both types of pain are shown in Table 1.
The NICE guidelines also describes ‘subthreshold depressive symptoms’, which fall below the criteria for major depression, nad are defined as atleast one key symptom of depression but with insufficient other symptoms and /or fumctional impairment to meet the cirteria for full diagnosis. Below outlines the NICE guidelines classification of depression, using the DSM-IV criteria Subtherapeutic depressive symptoms – Fewer than five symptoms of depression. Mild Depression – Few, if any, symptoms in excess of the five required to make an initial diagnosis, and symptoms only result in only minor functional impairment.
In moderate and severe depression, pharmacotherapy should be considered the mainstay of treatment. In milder depressive states, non-drug strategies may be considered preferable, though the two approaches are definitely not mutually exclusive. One method of ensuring the ‘least restrictive’ method of treatment for a patient may be to incorporate the stepped-care model. This approach provides the least intrusive, most effective intervention; if a person does not benefit from the initial intervention (or declines it), the should be offered an appropriate intervention from the next step. In this way, stepped care has the potential for deriving the greatest benefit from available therapeutic resources. Below is an example of a stepped-care model adapted from NICE 2009 –
FOCUS OF THE INTERVENTION
NATURE OF THE INTERVENTION
Step 4: Severe and complex depression1, risk to life and severe self neglect
Medication, high intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care
Step 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression
Medication, high intensity psychological interventions, combinbed treatments, colloborative care2, and referral for further assessment and interventions
Step 2: Persistent subthreshold depressive symptoms, mild to moderate depression
Low intensity psychosocial, interventions, psychological interventions, medication and referral for further assessment and interventions
Step 1: All known and suspected presentations of depression
Assessment, support, psychoeducation, active monitoring and referral for further assessment and interventions
1. Complex depression includes depression that shows an inadequate response to multiple treatments, is complicated by psychotic symptoms, and/or is associated with significant psychiatric comorditiy or psychosocial factors 2. Only for depression where the person also has a chronic physical mental health problem and associated functional impairment
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CPD 37: DEPRESSION
PHAMACOLOGICAL TREATMENT OF DEPRESSION Despite the advent of new antidepressant drugs, the therapeutic effectiveness of these agents has changed little since the discovery of imipramine in the late 1950s.2 The table below lists the commonly used antidepressant drugs, their class, method of action, and common side effects – (figure 1) Figure 1 – An overview of commonly prescribed antidepressants prescribed in Ireland Common Side Effects
Citalopram Escitalopram Fluoxetine Paroxetine Educational distance Sertraline
Selective Serotonin Reuptake Inhibitors (SSRIs)
GI upset, and bleeding Sleep disturbances Hyponatremia CNS Disturbances content for healthcare Agitation Weight gain Withdrawal symptoms Sexual dysfunction
Module 1 June 2012
Anticoagulants MAOIs Lithium
36 hours 30 hours 4-6 days 24 hours 22-36 hours
professionals in Ireland
Chronic Pain – assessment and management in primary care Venlafaxine Duloxetine
GI problems Constipation Hyponatremia Withdrawal symptoms Increased blood pressure and heart rate Cardiac arrhythmias
Ciprofloxacin Anticoagulants Some SSRIs Antimalarials
5-11 hours 8-17 hours
Amitriptyline Dosulepin/dothepin Trimipramine
Dry mouth, Sweating Blurred Vision, Constipation Urinary Retention Other anticholinergic effects Sedation Orthostatic hypotension Cardiac Toxicity
Adrenaline Alcohol Antiarrhythmics Anticonvulsants MAOIs Fluoxetine
9-25 hours 14-45 hours 7-23 hours
Monaamine Oxidase Inhibitors
Phenelezine Isocarboxazid Tranylcypromine Moclobemide
Higher risk of serotonin syndrome Severe withdrawal symptoms Hepatic impairment Postural Hypotension Insomnia Blood dyscrasias
Tyramine containg foods, Alcohol Antihypertensives, Anticonvulsants Levodopa, Sympathomimetics
3.9-4.8 hours (average)
Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs)
Alcohol, Analgesics Sheehan et al reported in 199620-24 thathours the estimated cost of Anticoagulants, Ketoconazole pain for 95 patients to the Irish Health Services when added Cimetide Pain is one of the commonest reasons for patients to seek to the amount of Social Welfare payments received and 5-13 hours Antiepileptics, Antimalarials Sedation Trazodone 1 Trazodone (increase NA activity shown that as many medical attention. A recent survey has Antivirals, Nitrates Postural hypotension the lost earnings of each patient amounted to 1.9 million Anticoagulants Tachycardia in Ireland as 8.3 visits per year to primary care physicians 6 Antimuscarinics GI upset pounds at the time of referral. The recent data from PRIME were due to symptoms of pain.2 A large scale survey carried survey show that the mean cost 1-2 per hourschronic pain patient Ciprofloxacin GI upset Agomelatine Agomelatine (melatonin receptor out in 15(Valdoxan) European countries and Israel in 2006, screening Antimalarials Constipation agonist, selective 5HT receptor isSSRIs estimated at €5,665 per year across all grades of pain, (fluvoxmine) antagonist) 46,394 respondents reported that theAgitation prevalence of chronic Atomoxetine Sleep Disturbances which was extrapolated to €5.34 billion or 2.86% of Irish pain of moderate to severe intensity inSweating adult Europeans was 7 GDP per year. This demonstrates an urgent need for cost 19%.3 the enhancing from better to particular antidepressants, adverse The NICE guidelines recommend effective strategies to antidepressant, manage chronicwhether pain effectively. Other agents Mirtazpaine (increases 5HT and NA activity)
GI upset Sedation Weight gain
effects notwithstanding. This has led to the use of SSRIs (figure 1) as the first line an pharmacodynamic/pharmacokinetc More recent survey data from another that study, carried out convention a response to a treatment pharmacotherapy for depression, according interaction, or an overdose of a sertonin is a strong to use that particular to the stepped-care approach outlined enhancing medicine.pain Symptoms range from in 2,019 people with chronic pain andindication 1,472 primary Understanding chronic drug in the treatment of a future episode.2 A above. The majority of antidepressant can be mild diarrhooea and tremor to reslessness, care across 16 15 European countries, have 2001 study comparing the effectivenessChronic of considered effective in up to physicians 80% of patients. myoclonus, convulsions and healing pain is definedconfusion, as pain that outlasts normal that chronic pain affects 12-54% of adult fluoxetine, paroxetine and sertraline concluded A four to six week initial demonstrated course is the norm in death.1 Management is based primarily on time (usually three to six months), and is most frequently that in similar in effectiveness, order to see optimum effects; in some cases stopping the usage of the precipitating drugs, Europeans, and its prevalence Ireland is up to 13%.2and Thethat potential patient tolerability was the deciding factor when associated withadministration musculoskeletal disordersantagonists such as low a twelve week course may be necessary. the of serotonin PRIME (Prevalence, Impact and Cost of 17 Chronic Pain) study, prescribing. Treatment should be maintained for at least sucharthritis. as cyproheptadine, and also supportive care back pain and However, it can be associated on thebe other hand, determined the prevalence of chronic six months before withdrawal attempted; including the control of agitation, the control with other disorders such as depression or metabolic SWITCING ANTIDEPRESSANTS and this withdrawal should of autonomic instability, and the control of painbetoundertaken be as high as 35.5% in Ireland.4 The PRIME study gradually unless the patient is experiencing disorders orhyperthermia. neurologic conditions such as multiple Additionally, those who ingest This should be conducted with caution, was designed to investigate the prevalence of chronic pain severe problems. SSRI discontinuation sclerosis. large doses of serotonergic agents may benefit as complications may include withdrawal syndrome is a documented condition whosethe psychological and physical health in Ireland; compare from gastrointestinal decontamination with symptoms, serotonin syndrome, and potential symptoms include GI symptoms, activated charcoal provided it is administered profiles ofheadache, those with and without chronic pain; explore pharmacokinetic andand pharmacodynamic Pain (acute or chronic) can be categorised as nociceptive giddiness, sweating, shaking and insomnia. 4 1 within an hour of overdose.18 interactions. Cross-tapering is encouraged, disability. Responses to survey questions were Extrapyrmadial reactionspain-related may occur upon or neuropathic. Nociceptive pain is caused by an active whereby the dose of the withdrawing drug is abrupt withdrawal of theobtained SSRIs.2 Depression POSTPARTUM DEPRESSION from 1,204 people. illness, injury and/or inflammatory process associated with slowly reduced while the new drug is slowly often has a remitting relapsing course, and introdcued over a 2-4 week period. Crossactual or potential tissue damage Nociceptive pain Postpartum depressioni.e. (PPD), also called symptoms often persist Despite betweenthe episodes. magnitude of the problem, pain is tapering maychronic not be necessary if switching postnatal depression, is a type of clinicalto actual Where possible, the key goal of an intervention results from activity in neural pathways secondary 2,5 a drug withininthe same care. therapeutic class; bothof under-recognised andtoundertreated primary depression that can affect women, and less should be to complete relief symptoms or potential tissue damage. Nociceptive pain is mediated particularly SSRIs (except fluoxetine which has frequently men, typically after childbirth. Studies (remission) which is associated Indeed,with up tobetter 38% of patients reported being inadequately a long half-life [fig 1] a ‘wash-out’ periodby may 13 pain receptors located in skin, system, report prevalence rates musculoskeletal among women from functioning and a lower likelihood of relapse. betheir recommended). managed in primary care for pain symptoms.2 In 5% to8 25%, but methodological In patients who have had multiple episodes, bone, and joints. Neuropathic pain, on thedifferences other hand, addition, people with chronic pain reported waiting up to among the studies make the actual prevalence there is evidence of benefit from maintenance SEROTONIN SYNDROME results fromrate direct injury to a peripheral or central sensory unclear. Among men, in particular new treatment for at least two years. is no seeking help and diagnosis, and 1.9 2.2 yearsThere between nerves do notofproduce transduction at fathers, the incidence postpartum depression strong evidence for the existence of a particular Serotonin syndrome is a2 potentially life- nerve; the affected years before their pain was adequately managed. 8 been estimated to be between 1-26%.19 has biochemical subtype of depression. However, threatening adverse reaction that may result nociceptors. Pain characteristics and associated conditions from the therapeutic use of a sertoninfor unknown reasons, some patients respond PPD has also been associated with impaired
for both types of pain are shown in Table 1.
use by Healthcare Professionals in the Republic of Ireland only Learning, Evaluation,For Accredited, Readers, Network | www.learninpharmacy.ie © Copyright 2012 Pfizer Healthcare Ireland Date of Preparation: Module 1 June 2012 EPBU/2012/XXX
CPD 37: DEPRESSION
child development.20 The choice of treatment is complicated by the fact that the woman may be breastfeeding. The risk-benefit assessment must include the risk to the mother of nonpharmacological intervention; the risk of exposing the baby to antidepressants; the benefits of breastfeeding, Module and the availability 1 of psychological therapies.21 The choice of June 2012 antidepressant drug should veer towards the one with the lower risk profile, and concomitant use of other sedating drugs should be avoided. mother has taken an antidepressant sionals Ifduring inthe Ireland her pregnancy (from conception to delivery), this therapy should be continued if deemed appropriate, and the infant should be monitored for possible toxicity – symptoms such as sedation, irritability and change in feeding patterns.20 Of the SSRIs, paroxetine and sertraline are the preferred options, while amitriptyline and imipramine are the preferred tricyclic antidepressants. Doxepin is definitely contraindicated in breastfeeding as it has a long-acting metabolite which may accumulate in breast-milk.22
anagement in primary care
the most significant, as this relationship can be established and any fears of the patient regarding their treatment can be allayed – patients often believe antidepressants to be addictive is one such misconception. The pharmacist must take into account that the patient may be distressed or have a short attention span (associated with depression) thus the information provided should be concise. At the very least, the patient may be glad of someone to talk to. The pharmacist can play a role in determining adherence in the important first two or three weeks, discuss potential side effects and interactions, and continue to be, in effect, a professional sounding board throughout the treatment, with due consideration given to time and qualification constraints. THE ‘STIGMA’ OF DEPRESSION
A 2007 HSE publication on attitudes on mental health in Ireland reported that 85% of people believe that ‘anybody can experience a mental health problem’, but 62% stated that ‘if I was experiencing mental health problems SEASONAL AFFECTIVE DISORDER I wouldn’t want anybody else knowing about it’. The prevailing attitude of the report, as Seasonal affective disorder (SAD) is a form outlined above, is that people may be more of recurrent depressive or bipolar disorder, willing to accept other people with mental with episodes that vary in severity. Seasonal health problems, than admit they are struggling patterns of depressive episodes are common, themselves, and that as a nation, introspection but SAD seems to be less common than such is not a strong facet of our personality. In patterns suggest. SAD was initially believed to the intervening years, depression may have be related to abnormal melatonin metabolism, become more socially acceptable. The ubiquity later findings didthat not the support this cost of ehan et but al reported in 1996 estimated of social media brings high profile cases to the hypothesis. Studies of brain serotonin function n for 95 patients to the Irish Health Services when added public consciousness: the Cork hurler Conor support the hypothesis of disturbed activity. Cusack, and footballer Stan Collymore, the he amount Social Welfare paymentsfor received and Theofshort-allele polymorphism serotonin latter with 500,000 followers on twitter, have transporter is more common in patients with lost earnings of each patient amounted to 1.9 million offered candid insights into their struggles with SAD than in healthy people. Atypical depressive 6 nds at the time of referral. The recent impaired data from PRIME the illness, and brought awareness to the public symptoms commonly precede zeitgeist like never before. However, having vey showfunctioning, that the mean per symptoms chronic pain and cost somatic arepatient a more socially acceptable disease does not frequently the presenting complaint at visits to stimated at €5,665 per year across all grades of pain, dilute the nature or seriousness of the illness, family physicians. The best treatment regimens the impact on the patient and their family, or the ch was extrapolated €5.34 billion orlight 2.86% of Irish include 2500 to lumen of artificial exposure 23 SSRIs an areurgent a useful alternative in 7the morning. P per year. This demonstrates need for cost importance of adherence to treatment; having the flu is socially acceptable too, but the patient if the latter is not effective Botheffectively. fluoxetine ctive strategies to manage chronic- pain still requires convalescence and a course of and light therapy are 67% effective in treating treatment. This increased public awareness may SAD according to direct head-to-head trials prompt a patient to recognise the symptoms of conducted in a 2006 Canadian study.24 derstanding chronic pain the disease in themselves or others and thus lead to an earlier intervention. PHARMACEUTICAL CARE onic painCONSIDERATIONS is defined as pain that outlasts normal healing IN DEPRESSION CONCLUSION e (usually three to six months), and is most frequently Pharmacists are well placed to adopt a ociated with musculoskeletal disorders such as low Depression is a serious, debilitating illness substantial role in primary depression care, k pain and arthritis. However, it can also be provided associated with various levels of severity which requires complementing the role of the GPs, a multidisciplinary treatment plan. A steppedmitigatingsuch factors such as attitudes, training, h other disorders as depression or metabolic care approach may be the most efficient, as current practices and barriers are addressed. outlined in the NICE guidelines. As pharmacists, orders orStudies neurologic conditions such as multiple suggest that, despite their willingness, we can offer practical and emotional support rosis. pharmacists are underused in this role; citing to depressed patients. However, supplemental time constraints, lack of training, and an training for pharmacists, extending beyond the absence of can a culture of cooperation with GPs to n (acute or chronic) be categorised as25nociceptive medical, may be needed to provide holistic care be the main barriers in this regard. to a patient; considering that a pharmacist may europathic. Nociceptive pain is caused by an active be the sole healthcare professional a patient do need to set aside any ss, injuryPharmacists and/or inflammatory process associated with may encounter for considerable lengths of time entrenched views or misguided opinions on ual or potential tissue damage i.e. Nociceptive pain during their treatment. depression and treat each patient on their
ults from merit. activityPharmacists, in neural pathways secondary to actual in general, have a positive REFERENCES towards Nociceptive depression and shown to otential attitude tissue damage. painare is mediated 1 Pharmacotherapy of depression in adults. NMIC Bulletin a positive impact on both patient treatment and 2010; Vol 6: 6. Available online at www.nmic.ie. Accessed pain receptors located in skin, musculoskeletal system, 26,27 18th March 2011 Pharmacists must first be willing outcome. 8 2 Walker and Edwards Clinical Pharmacy and Therapeutics e, and joints. Neuropathic pain, the other hand, to engage the patient in aon private, discrete 3 edition Churchill Livingstone Publishers 2003; manner, thus building a trusting relationship. 29: 465-480 ults from direct injury to a peripheral or central sensory The patient should not feel that they are being 3 Gorman J, Gender differences in depression and response to ve; the affected nerves do not produce transduction at psychotropic medication. Gender Medicine 2006; 3:93-110 judged, or are subject to the perceived stigma 8 iceptors.of Pain characteristics and associated conditions 4 Ebmeirer K et al Recent developments and current depression. The initial consult is probably both types of pain are shown in Table 1. rd
controversies in depression Lancet 2006; 367: 153-67 5 Accessed from http://www.blackdoginstitute.org.au/docs/ causesofdepression.pdf December 14th 2013 6 Flett, G. L.; Hewitt, P. L. (2002). Perfectionism. Washington, DC: American Psychological Association. pp. 5–31. 7 Watkins E, Teasdale J Adaptive and maladaptive self-focus in depression Journal of Affective Disorders 2004; 82:1-8 8 Walker and Edwards Clinical Pharmacy and Therapeutics 4th edition Churchill Livingstone Publishers 2003; 29: 465-480 9 Pompili M et al Hypothalamic pituitary adrenal axis and prolactin abnormalities in suicidal behavior CNS Neurol Disord Drug Targets. 2013 Nov;12(7):954-70. 10 Zitner D Depression – Is it really medical? The Canadian Journal of Diagnosis 2005 pp 88-90 11 ICD-10 Classification of Mental and Behavioural Disorders, WHO publications, Geneva 1992 12 American Psychiatric Association Diagnositc and Statistical Manual of Mental Disorders (4th edition), American Psychiatric Association, Washington DC 1994 13 Depression: the treatment and management of depression in adults (CG90), National Institute of Health and Clinical Evidence, UK 2009. Available at www.nice.org.uk 14 Hermens M Prognosis of minor depression in the general population: a systematic review. General Hospital Psychiatry 2004; 26: 453-62 15 Bower P Stepped care in psychological therapies: access, effectiveness and efficiency The British Journal of Psychiatry 2005; 186: 1-11 16 Mann JJ The medical management of depression The New England Journal of Medicine 2005; 353: 1819-34 17 Kroenke K et al. Similar effectiveness of paroxetine, fluoxetine, and sertraline in primary care American Medical Association 2001; 23: 2947-2954 18 Sporer K The serotonin syndrome. Implicated drugs, pathophysiology and management. Drug Safety 1995; 13 (2): 94–104 19 Paulson J Focusing on depression in expectant and new fathers: prenatal and postpartum depression not limited to mothers” Psychiatry Times 2010; 27: 1-2 20 NMIC Frequently asked questions on use of antidepressants in adults 2011; 11: 1-5 21 Payne J Antidepressant use in the postpartum period: practical considerations The American Journal of Psychiatry 2007;164:1329-1332 22 NICE clinical guideline 45 – Antenatal and postnatal mental health, February 2007 (reissued April 2007) downloaded from www.nice.org 23 Partonen Timo et al Seasonal affective disorder The Lancet 1998; 352:1369- 1374 24 Lam, Raymond W et al. The Can-SAD Study: A Randomized Controlled Trial of the Effectiveness of Light Therapy and Fluoxetine in Patients With Winter Seasonal Affective Disorder The American Journal of Psychiatry 2006 163 (5): 805–812. 25 Scheerder G et al Pharmacists role in depression care: A survey of attitudes, current practice and barriers Psychiatric Services 2008; 10: 1176 26 Brook O, van Hout H, Nieuwenhuyse H, Heerdink E. Impact of coaching by community pharmacists on drug attitude of depressive primary care patients and acceptability to patients; a randomized controlled trial. Euro Neuropsycho pharmacol. 2003;13:1-9. 27 Bostwick J Diez L Optimizing care for patients with depression in the community pharmacy setting US Pharmacist 2008;33(11): 24-28
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