AFFECTIVE DISORDERS LONGTERM TREATMENT OF DEPRESSION

1
AFFECTIVE DISORDERSLONG-TERM TREATMENT OF
DEPRESSION

• PROF. MUDr. JIRÍ RABOCH
• LF UK A VFN
• PRAHA

2
AFFECTIVE DISORDERSin the history

• 4. b.c. Hippokrates - melancholy, mania
• 1899 Kraepelin manic depressiv psychosis
• 1953 Kleist, Leonhard - unipolar x bipolar
  depression

3
Paradigms of depression and its treatment
4
THE GLOBAL BURDEN OF DISEASECh.J.L.MURRAY,
A.D.LOPEZ, 1997

• HARVARD SCHOOL OF PUBLIC HEALTH
• WORLD HEALTH ORGANISATION
• WORLD BANK

5
DALY - Disability Adjusted Life Years DALY
YLL YLD

• YLL - Years of Life Lost
• YLD - Years Lived with Disability

6
DALY OF NEUROPSYCHIATRIC DISORDERS IN VARIOUS
PARTS OF THE WORLD
Murray a Lopez, 1997
Disability Adjusted Life Years
7
10 MAIN CAUSES OF DEATHestablished market
economies
Murray a Lopez, 1997
Years of Life Lost
8
10 MAIN CAUSES OF DISABILITIES established
market economies
Years Lived with Disability
Murray a Lopez, 1997
9
DALY ()world
Murray a Lopez, 1997
10
DALY () established market economies
Murray a Lopez, 1997
11
DALY () established market economies age 15 -
44
Murray a Lopez, 1997
12
DALYformerly socialist countries
Murray a Lopez, 1997
13
LIFE-TIME PREVALENCE ()NCS
Kessler, 1994
14
Cumulative frequency of depression according to
the decade of birth and the age at the start of
the disease ECA study
1945-1954
1935-1944
1955
1925-1934
1915-1924
1905-1914
? 1905
Wittchen et al., 1994
15
FIRST OUT-PATIENT PSYCHIATRIC EVALUATION DURING A
YEAR (2 450 106 EVALUATIONS)
ÚZIS 2005
16
CUMULATIVE FREQUENCY OF RELAPSES OF DEPRESSION
(378 patients with depressive disorder)
Cumlative frequency ()
years
Rothschild, A. J., 1999)
17
LONG-TERM COURSE OF DEPRESSION
7 15 commits suicide
2/3 suicidal ideas
Keller a Sadock, 1991
18
NUMBER OF COMMITED SUICIDES/100 000
WHO 2000
19

COMITTED SUICIDES CZECH REPUBLIC /100 000
ÚZIS 2003
20
CZECH REPUBLIC

• 2002 - COMMITED SUICIDES 1483
• (1 173 men a 310 women)
• ÚZIS 2003

21
FACTORS INFLUENCING THE COURSE OF DEPRESSION

• GENETIC RISK
• AGE AT THE START OF DEPRESSION (lt25, 60lt)
• NUMBER OF PREVIOUS EPIZODES AND THEIR LENGTH
• REZIDUAL SYMPTOMS
• COMORBIDITY
• FEMALE GENDER
• PSYCHOSOCIAL SITUATION (PARTNER)
• BIOLOGICAL FACTORS SLEEP PATTERN, HHA ACTIVITY

22
PHASES OF DEPRESSION TREATMENT
Depression intensity
time
acute continuing maintenance
(Kupfer, 1991)
23
DEPRESSION TREATMENT OPTIONS

• ANTIDEPRESSANTS, OTHER DRUGS
• PSYCHOTHERAPY (KBT, IPT)
• OTHER BIOLOGICAL METHODS
• ECT
• rTMS
• PHOTOTHERAPY
• SLEEP DEPRIVATION
• VNS, DBS

24
PHASES OF DEPRESSION TREATMENT
Depression intensity
time
acute continuing maintenance
(Kupfer, 1991)
25
FINISHING THE CONTINUING TREATMENT PHASE

• 4 9 MONTHS OF EUTHYMIA
• NOT FULFILLING THE CRITERIA FOR MAINTENANCE
  TREATMENT
• THE PATIENT IS ASKING FOR
• DISCONTINUATION SYNDROM TCA,
  
  SSRI WITH SHORT-TERM ELIMINATION HALF-TIME
• SLOWLY DECREASING THE DAILY DOSAGE - 25 DD PER
  MONTH

26
PHASES OF DEPRESSION TREATMENT
Depression intensity
time
acute continuing maintenance
(Kupfer, 1991)
27
MAINTENANCE THERAPY
Maixner a Greden, 1998
28
MAINTENANCE TREATMENT(LONG-TERM)

• WHAT ANTIDEPRESSANT
• WHAT DOSAGE
• HOW LONG

29
WHAT ANTIDEPRESSANT?
30
MAINTENANCE TREATMENT(LONG-TERM)

• LITHIUM
• CLASSICAL ANTIDEPRESSANTS
• IMAO, RIMA
• SSRI
• OTHER MODERN ANTIDEPRESSANTS

31
RESUTLTS OF MAINTENANCE TREATMENT WITH
IMIPRAMINE IN 4. AND 5. YEARS IN COMPARISON WITH
PLACEBO
Imipramin (n11)
Cumulative frequency of patients in remissioni
Placebo (n9)
plt0,006
(Kupfer, D.J., et al., 1992)
32
SSRIs inhibition of P450 microsomal enzymes
(Edwards, J.G. a Anderson, I., 1999
33
POTENTIALLY SERIOUS DRUG INTERACTIONS OF SSRIs
34
MAINTENANCE DEPRESSION TREATMENT

• SSRIs gt CLASSICAL ANTIDEPRESSANTS SIMILAR EFFECT
  
  BETTER
  TOLERABILITY
  COMORBID DISORDERS
  ONCE A DAY DOSAGE
  LOW INTOXICATION LETHALITY
• ANDERSON, 1998

35
HOW LONG?
36
Recurrences in 105 patients with major depression
after 5 years-remission
(Mueller, T.I., et al., 1999)
37
WHAT DOSAGE?
38
DOSAGES OF ANTIDEPRESSANTS IN MAINTENANCE
TREATMENT OF DEPRESSION

• IMIPRAMINE 3-YEARS FOLLOW-UP
• 100 mg - 70 RELAPSES
• 200 mg - 30 RELAPSES (FRANK et al., 1993)
• CITALOPRAM 20 i 40 mg EFFECTIVE IN CONTINUING
  TREATMENT (MONTGOMERY et al., 1993)
• DECREASING THE DOSAGE OF CITALOPRAM FROM 40 TO 20
  mg 2-YEARS FOLLOW-UP 50 RELAPSES (FRANCINI et
  al.,1999)

39
COMPLIANCE

• STRATEGIES FOR IMPROVING
• PATIENT PHYSICIAN RELATIONSHIP
• EDUCATION
• ADEQUATE FARMAKOTHERAPY
• Haddad, 2000

40
PSYCHOFARMACOLOGICAL THERAPY ONLY 13,4 OF
PEOPLE WITH DEPRESSIVE SYMPTOMS (!!!)
Vanek, Raboch, Vanek, 2000