Contents
Key Points
  • Encourage all your DVA patients with depression to participate in psychological therapies
  • Avoid routinely starting patients with mild to moderate depression on an antidepressant
  • Tap into the DVA mental health resources that are available (see insert E-Mental health resources available to DVA patients)
  • Every six months re-evaluate the need for ongoing use of an antidepressant based on your patient’s individual circumstances

Achieving best outcomes for depression

Depression is common among Australian veterans.1 Analysis of Australia’s Department of Veterans’ Affairs (DVA) health claims data indicates duration of antidepressant use is often inconsistent with clinical guidelines and non-pharmacological therapies are underused.2, 3

Most people with depression have a mild to moderate form, and with appropriate care, most recover within a year.4 Up to 80% of people have at least two recurrences during their lifetime, and for a small proportion of people, depression becomes a chronic illness.4, 5

Current guidelines recommend using a stepped care approach for treating depression.4-6 Where the DVA patient is willing and able to participate, non-pharmacological therapies are recommended as first-line treatments for mild to moderate depression.4-7 For more severe depression, antidepressants are recommended in conjunction with non-pharmacological therapies.4-6, 8

Offer early referral for psychological support

First-line treatments for mild to moderate depression include individual guided self-help therapies based on the principles of cognitive behavioural therapy (CBT) (see insert), and education about lifestyle changes, including mood monitoring, exercise and healthy sleep patterns.6, 7 Behavioural activation used either in a guided self-help format over the telephone with a low intensity coach, such as the beyondblue NewAccess program (see insert), or face-to-face sessions with a high intensity CBT practitioner, such as a psychologist, is recommended.9, 10

Some patients might prefer telephone or electronic interventions; others might prefer face-to-face sessions. No matter the mode of intervention, reviewing your patient each week or fortnight, and making contact with them if they don’t attend follow up appointments, allows you to monitor changes in their mood, encourages adherence and completion of programs, and has an overall positive effect on their recovery.6, 11

For DVA patients with mobility problems, consider arranging psychological interventions, including CBT, problem solving therapy or family therapy, with exercise interventions in their home. Evidence suggests home-based psychological therapies combined with exercise are as effective in reducing symptoms of depression as when the patient attends a clinic.12 DVA can pay for assessment and treatment by a psychologist or social worker for eligible DVA patients who are not able to travel.13 https://www.dva.gov.au/sites/default/files/files/providers/alliedhealth/notes_for_AHPs-sec1.pdf

Finding a health professional who can provide support

DVA has expanded eligibility for mental health conditions. Now, anyone who has ever served in the permanent forces of the Australian Defence Force may receive treatment for any mental health condition, regardless of when they served, for how long, or the nature of their service. This is known as non-liability health care. DVA will pay for treatment for DVA patients with depression whatever the cause, even if the condition is not related to service. For further information, go to DVA at: http://at-ease.dva.gov.au/veterans/take-action/access-to-treatment/

If access to a psychologist or other healthcare professional trained in non-pharmacological therapies is not possible, consider low intensity guided self-help interventions, such as Mindspot Clinic, moodGYM or other e-mental health resources via the DVA portal for your DVA patients, especially those programs that require GP involvement (see insert E-Mental health resources available to DVA patients).

The RACGP has developed ‘e-Mental health: A guide for GPs’ to assist GPs in using e-mental health interventions in primary care and is available at: http://www.racgp.org.au/your-practice/guidelines/e-mental-health/

Antidepressants provide little therapeutic benefit for mild to moderate depression

Australia has one of the highest rates of antidepressant use in the world.16 The benefit of an antidepressant compared with placebo increases with the severity of depression.17 Antidepressants provide little benefit for most people with mild to moderate depression.17 They are most beneficial for people with severe depression,17 especially when used in conjunction with psychological therapies.5, 8 The UK National Institute of Clinical Excellence’s threshold for clinical significance (a Hamilton Depression Rating Scale point difference of ≥3) was only met for HDRS scores of 25 or greater (see Figure 1).17

Figure-1

Figure 1: A meta-analysis of six studies indicates the mean change in depressive symptoms according to the Hamilton Depression Rating Scale (HDRS) for antidepressant medicine and placebo for mild, moderate, severe and very severe depression.17

In people with mild to moderate depression, the adverse effects associated with antidepressant use might outweigh the benefits. Consider potential adverse effects and drug interactions before starting an antidepressant. See the ‘Australian Medicines Handbook’.

Older people are often more susceptible to adverse effects than younger people because of multi-morbidity, other medicines they are taking and frailty.18 As with younger people, antidepressants are most effective in those with severe depression and when used in conjunction with psychological therapies.19

Persistent depressive disorder (dysthymia)5, 20 & Sub-threshold depression6, 21-23
  • There are other depressive disorders, including persistent depressive disorder (PDD) and sub-threshold depression, that fall outside the criteria for depression, but are relatively common in DVA patients.
  • DVA patients with these disorders might not actively seek help, and may go unrecognised and untreated.
  • Early diagnosis and treatment is important as DVA patients with PDD or sub-threshold depression often experience significant morbidity including impairment in social and occupational functioning, and increased physical ailments and risk of suicide.
  • When treating DVA patients with PDD or sub-threshold depression, encourage participation in psychological therapies, especially CBT-based self-help interventions before considering medicines.

A combined treatment approach is most effective for more severe depression

For most patients with moderate depression, psychological therapies alone are an effective treatment, especially if provided early in the illness.19, 24 Patients with more severe depression are likely to benefit the most from an antidepressant in conjunction with face-to-face psychological therapies.5, 11 Psychological therapies have been found to have an additional positive effect in treating depression, apart from the effects from pharmacotherapy.8 The combined effect of pharmacotherapy and psychological therapies compared with placebo is estimated to be twice that of pharmacotherapy alone.8

Some DVA patients might have complex physical and mental health issues, including post-traumatic stress disorder (PTSD), anxiety, cognitive impairment, substance use disorders or chronic pain.25 These comorbid disorders require management of their own, if the patient’s depression is to respond fully to treatment.25, 26 Certain antidepressants might be inappropriate for some patients with complex issues due to their adverse effect profile or lack of evidence of effectiveness.19

Review the effect of potential interactions of the antidepressant with other medicines the patient is taking, including oxycodone or tramadol.19

Up to two thirds of people with depression will not respond to the first antidepressant they take.7, 27 If there is no response after at least four weeks of taking an adequate dose of an antidepressant; review the diagnosis, re-check adherence, switch to another antidepressant or refer your patient to a psychiatrist.5, 7

Encourage involvement of the DVA patient’s family where possible; their involvement and support can provide a sense of connection and belonging for the patient, aid recovery and lessen the risks associated with suicidal behaviour.25 Because living with a person with depression can affect family members, consider the impact on them and refer as needed.25

Before starting an antidepressant, patients prefer:26
  • to talk about realistic treatment options and goals and to know that decisions will be mutually agreed upon
  • an explanation of the possible cause of depression and what to expect when taking an antidepressant and how it might help
  • to know how long before the antidepressant might start to have an effect and the approximate length of time it will need to be taken for
  • to be informed of the possible adverse effects, and to have all reports of adverse events experienced taken seriously.

Review duration of antidepressant use

There is limited research to indicate optimal duration of antidepressant treatment.5 However, patients who have had full resolution of symptoms might benefit from a review of their antidepressant medicine.6

As a general guide, current guidelines recommend:

  • Continuation of an antidepressant after full resolution of symptoms for six to 12 months for patients following a single episode of depression.5, 24
  • Continuation of an antidepressant for at least two to three years for patients with two prior episodes of depression.5-7
  • Patients with depression who are resistant to antidepressant treatment and psychological therapies, or those with severe depression, should be referred to a psychiatrist for management.11
  • Patients with severe depression and suicidal thoughts or psychotic symptoms should have crisis intervention and be managed by a psychiatrist.18

DVA patients with a history of previous episodes of depression, particularly if they have been severe and associated with suicidality, and those with co-morbid disorders, including PTSD and coronary heart disease might benefit from ongoing therapy.11, 25, 28, 29 Every six months, re-evaluate the need for ongoing use of an antidepressant, based on your patient’s individual circumstances.

When considering tapering and ceasing an antidepressant, introduce the concept of stopping the antidepressant with your patient over several visits before you start tapering; some patients might feel anxious about stopping, especially if they have been taking an antidepressant for some time.27, 30 Abruptly stopping is generally not recommended unless a serious adverse event has occurred, for example a cardiac arrhythmia in a person taking a tricyclic antidepressant (TCA).7 Almost all antidepressants have the potential to cause discontinuation symptoms when they are stopped or rapidly reduced after being taken for six weeks or longer.7, 27

Consider antidepressant cessation carefully in high-risk patients, as relapse in these patients could initiate life-threatening behaviours.27

Tapering and ceasing an antidepressant5, 7, 27, 30

Discuss and negotiate a tapering plan with your patient and include their partner or close family members if appropriate. Schedule more frequent visits to closely monitor your patient’s progress, and to detect any early signs and symptoms of re-emerging depression.

Consider and manage potential drug interactions caused by cessation of the antidepressant.

Inform your patient of potential discontinuation symptoms that might occur as the dose is tapered down. Discontinuation symptoms are usually mild and transient, but for some, they can be more severe and troublesome. Refer to the ‘Australian Medicines Handbook’ for discontinuation symptoms associated with antidepressants.

Taper the dose slowly over an extended period of time (at least four weeks or even months). Slow the tapering rate towards the end as discontinuation symptoms might not appear until reduction in the total daily dose is substantial.

The patient might experience some discontinuation symptoms from any of the classes of antidepressants, even with gradual tapering, but the risk is greater with higher doses and with longer duration of treatment.

Discontinuation symptoms are most severe with venlafaxine, and frequently occur with duloxetine, desvenlafaxine and short-acting SSRIs, especially paroxetine. Discontinuation symptoms are less likely with fluoxetine, because of its long half-life, especially if the dose is less than 40mg.

If discontinuation symptoms are severe, reintroduce the antidepressant, or another with a longer half-life from the same class, and taper gradually while monitoring for symptoms.

If your patient is taking an SSRI or an SNRI and finding withdrawal symptoms burdensome, switching to fluoxetine might help to alleviate symptoms. It can usually be stopped later without discontinuation symptoms reappearing.

Suddenly stopping a TCA can cause anticholinergic rebound symptoms including Parkinson-like symptoms, balance disturbances, flu-like symptoms, myalgia and gastrointestinal problems.

For further guidance refer to ‘Switching and stopping antidepressants’ at: https://www.nps.org.au/australian-prescriber/articles/switching-and-stopping-antidepressants

E-Mental health resources available to DVA patients

DVA patients can access effective internet and related electronic communication technologies, services and care.

Programs can be used for early intervention, as first-line or adjunctive therapies or as a tool to reduce relapse. Online programs enable people, especially those in rural or remote areas, to access help that is convenient and flexible in a private and confidential manner.31

The DVA Mental Health Services and Resources for Health Providers and their Clients provides a comprehensive list of services, websites, apps and publications for providers as well as clients, and how to access each one. It is available at: http://at-ease.dva.gov.au/professionals/files/2015/12/DVA-Mental-Health-Services-and-Resources-Dec-2015.pdf

Veterans with depression might not present with a complaint of depression; they might seek help for other complaints, including insomnia or pain, or they might be excessively worried about physical ailments.25

Consider the ADF Post-discharge GP Health Assessment for your veteran patients to help identify and diagnose physical and mental health problems.

The assessment is funded under the health assessment items 701, 703, 705 and 707 on the Medicare Benefits Schedule and can be accessed at: http://at-ease.dva.gov.au/professionals/files/2015/08/GP-Health-Assessment-Tool-updated-15-July-15.pdf

For detailed information about the assessment, go to: http://at-ease.dva.gov.au/professionals/assess-and-treat/adf-post-discharge-gp-health-assessment/

At-Ease-Logo

Encourage your DVA patients to visit the DVA portal to access online programs and mobile apps: http://at-ease.dva.gov.au/professionals/clinical-resources/depression/

Online programs
  • High Res website offers a range of free interactive tools and self-help resources for DVA patients to help manage stress and build resilience.
  • MoodGYM is a free cognitive behavioural therapy (CBT)-based program that enables patients to learn and practise skills to prevent and manage symptoms of depression and anxiety. It can be accessed anytime, is anonymous and has been scientifically evaluated.
  • This Way Up Clinic is a CBT-based program that patients can undertake themselves as a self-help course on a desktop or mobile device, or a clinician can prescribe the course and supervise their patients as they work through the lessons. There is a small cost to access the program.
  • eCouch is an interactive CBT and interpersonal therapy-based program for depression, anxiety, relationship difficulties and grief.
  • MindSpot Clinic is a free telephone and online assessment, treatment and referral service for people with depression or anxiety.
Mobile device apps
  • LifeArmor provides information on depression, sleep, post-traumatic stress disorder and relationship issues to DVA patients. It is available for Apple and Android products.
  • T2 Mood Tracker allows DVA patients to self-monitor and track changes in their emotional state. It is available for Apple and Android products.
  • High Res offers a range of interactive tools, self-help resources and videos which have been specifically developed for DVA patients to help manage stress and build resilience. It is available for free from the iOS App Store and Google Play.
  • Operation Life is a mobile app designed to help DVA patients deal with suicidal thoughts and is recommended to be used with the support of a clinician. The app provides on-the-go access to emergency and professional support and self-help tools to help stay calm and take action to stay safe.
Other E-Mental health resources available
  • NewAccess is a confidential beyondblue project for people with mild to moderate depression who are currently not seeing a psychologist or psychiatrist, and have not seen one in the last six months. The service provides a trained coach who completes an initial assessment and delivers six free sessions tailored to the needs of the person over the telephone, via the internet or face-to-face. The program delivers low intensity CBT, including graded exposure and behavioural activation, support in accessing community networks and educational programs. It also provides ongoing supervision to promote adherence. The program is aimed at people who might be reluctant or unable to access mental health services, for example, men and people in rural communities, where access to traditional mental health services is often lower than in cities.9, 10 It is currently accessible in Brisbane North, Brisbane South, Canberra, South Australia, Riverina/Murrumbidgee, South Western Sydney, Central and Eastern Sydney, North Coast NSW and surrounding areas. For further information, access the website at: https://www.beyondblue.org.au/get-support/newaccess
  • Encourage your patient to develop a plan to help manage symptoms of depression and to stay well. The Stay well plan at beyondblue helps people to identify personal triggers and early warning signs of a potential relapse, and enables coping mechanisms to be implemented promptly. Access Staying well: recovering from anxiety and depression at: www.beyondblue.org.au/get-support/recovery-and-staying-well/staying-well
  • MyCompass is a free, personalised self-help CBT-based program for people with mild to moderate depression, anxiety or stress that can be accessed via a mobile phone, computer or tablet. Developed by the Black Dog Institute, it is supported by the Department of Health and is available 24 hours a day, seven days a week at: https://www.mycompass.org.au/
  • Beacon is a website that provides global resources for mental health, at: https://beacon.anu.edu.au/
Psychological therapies for treating depression
  • Behavioural Activation is as effective as CBT, does not require a highly trained professional to deliver the program, and is free via the NewAccess program by beyondblue.9 It takes the approach that depressed mood is a common outcome from negative or stressful life events. It encourages and guides patients to gradually participate in activities that are enjoyable to them, while aiming to reverse the pattern of avoidance, withdrawal and inactivity that contributes to worsening depression.9
  • Cognitive Behavioural Therapy includes structured problem solving, activity scheduling and cognitive therapy to address and modify excessively negative thoughts and behaviours that help to maintain depression.25 CBT is well suited to be delivered electronically, especially for patients with mild depression where face-to-face contact might not be needed or wanted.
  • Mindfulness-Based Cognitive Therapy teaches the patient self-awareness and how to focus on the present moment to avoid thinking about unpleasant thoughts and feelings associated with the past or future.25 MBCT and Interpersonal Therapy are as effective as second generation antidepressants in reducing relapse from treated depression.32
  • Interpersonal Psychotherapy helps the patient to understand the link between mood and interpersonal relationships, and to develop skills to better cope with grief and conflict, role transition and to improve relationships.25

References

  1. Foreign Affairs, Defence and Trade Committee. Mental health of Australian Defence Force members and veterans. Commonwealth of Australia. March 2016. Canberra, ACT.
  2. Lu C and Roughead E. New users of antidepressant medications: first episode duration and predictors of discontinuation. Eur J Clin Pharmacol. 2012; 68: 65-71.
  3. DVA Health Claims Database, University of South Australia, QUMPRC. [Accessed September 2017].
  4. Bauer M, Pfennig A, Severus E, Whybrow P, Angst J, Moller H on behalf of the Task Force on Unipolar Depressive Disorders. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders. The World Journal of Biological Psychiatry. 2013; 14: 334-85.
  5. Malhi G, Bassett D, Boyce P, Bryant R, Fitzgerald P, Fritz K, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian and New Zealand Journal of Psychiatry. 2015; 49(12): 1087-1206.
  6. National Institute for Health and Care Excellence. Depression in adults: recognition and management. United Kingdom. 2009. Available at: https://www.nice.org.uk/guidance/cg90/resources/depression-in-adults-recognition-and-management-975742636741 [Accessed September 2017].
  7. Taylor D, Paton C and Kapur S. The Maudsley Prescribing Guidelines in Psychiatry. 12th Edn. Oxford, United Kingdom. Wiley Blackwell. 2015.
  8. Cuijpers P, Dekker J, Hollon S and Andersson G. Adding psychotherapy to pharmacotherapy in the treatment of depressive disorders in adults: a meta-analysis. J Clin Psychiatry. 2009; 70: 1219-29.
  9. Richards D, Ekers D, McMillan D, Taylor R, Byford S, Warren F, et al. Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial. The Lancet. 2016; 388: 871-880.
  10. Cromarty P, Drummond A, Francis T, Watson J and Battersby M. NewAccess for depression and anxiety: adapting the UK Improving Access to Psychological Therapies Program across Australia. Australasian Psychiatry. 2016; 24(5): 489-92.
  11. Anderson J, Galvez V, Loo C and Mitchell P. Adult depression: a step-by-step guide to treatment. Medicine Today. 2015; 16(11): 16-24.
  12. Sukhato K, Lotrakul M, Dellow A, Ittasakul P, Thakkinstian A and Anothaisintawee T. Efficacy of home-based non-pharmacological interventions for depression: a systematic review and network meta-analysis of randomised controlled trials. BMJ. 2017; 7: e014499. doi:10.1136/bmjopen-2016-014499.
  13. Australian Government Department of Veterans' Affairs. Notes for Allied Health Providers: Section One: General. Canberra, ACT. 2016.
  14. Schuch F, Vancampfort D, Richards J, Rosenbaum S, Ward P and Stubbs B. Exercise as a treatment for depression: a meta-analysis adjusting for publication bias. Journal of Psychiatric Research. 2016; 77: 42-51.
  15. Mammen G and Faulkner G. Physical activity and the prevention of depression: a systematic review of prospective studies. American Journal of Preventive Medicine. 2013; 45 (5): 649-57.
  16. Davey C and Chanen A. The unfulfilled promise of the antidepressant medications. The Medical Journal of Australia. 2016; 204 (9): 348-50.
  17. Fournier J, DeRubeis R, Hollon S, Dimidjian S, Amsterdam J, Shelton R, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA. 2010; 303 (1): 47-53.
  18. Mohammed M, Moles R and Chen T. Medication-related burden and patients' lived experience with medicine: a systematic review and metasynthesis of qualitative studies. BMJ Open. 2016; 6: e010035.doi:10.1136/bmjopen-2015-010035.
  19. Australian Medicines Handbook. Adelaide. Australian Medicines Handbook Pty Ltd. 2017.
  20. Ishizaki J and Mimura M. Dysthymia and apathy: diagnosis and treatment. Depress Res Treat. 2011; Article ID 893905, doi: 10.1155/2011/893905.
  21. Cuijpers P and Smit F. Subthreshold depression as a risk indicator for major depressive disorder: a systematic review of prospective studies. Acta Psychiatr Scand. 2004; 109: 325-331.
  22. Buntrock C, Ebert D, Lehr D, Smit F, Riper H, Berking M, et al. Effect of a web-based guided self-help intervention for prevention of major depression in adults with subthreshold depression: a randomized clinical trial. JAMA. 2016; 315 (17): 1854-63.
  23. Karsten J, Hartman C, Smit J, Zitman F, Beekman A, Cuijpers P, et al. Psychiatric history and subthreshold symptoms as predictors of the occurrence of depressive or anxiety disorder within 2 years. Br J Psychiatry. 2011; 198: 206-12.
  24. Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited. March 2017. Available at: http://online.tg.org.au/ip/desktop/index.htm [Accessed July 2017].
  25. Australian Centre for Posttraumatic Mental Health. Mental Health Advice Book for Practitioners Helping Veterans with Common Mental Health Problems, Australian Government Department of Veterans' Affairs. Canberra, ACT. 2012. Available at: http://at-ease.dva.gov.au/professionals/files/2014/09/P01621-Mental-Health-Advice-Book.pdf [Accessed September 2017].
  26. Anderson C, Kirkpatrick S, Ridge D, Kokanovic R and Tanner C. Starting antidepressant use: a qualitative synthesis of UK and Australian data. BMJ Open. 2015; 5: e008636.
  27. Keks N, Hope J and Keogh S. Switching and stopping antidepressants. Australian Prescriber. 2016; 39: 76-83.
  28. Van der Kooy K, van Hout H, Marwijk H, Marten H, Stehouwer C and Beekman A. Depression and the risk for cardiovascular diseases: systematic review and meta analysis. Int J Geriatr Psychiatry. 2007; 22: 613-26.
  29. Litchman J, Bigger J, Blumenthal J, Frasure-Smith N, Kaufmann P, Lespérance F, et al. Depression and coronary heart disease. Circulation. 2008; 118: 1768-1775.
  30. Haddad P and Anderson I. Recognising and managing antidepressant discontinuation symptoms. Advances in Psychiatric Treatment. 2007; 13: 447-457.
  31. Johnson C, Andronis C, Antoniadis J, Gunn J, Howell C and Orman J. e-Mental health: a guide for GPs. Melbourne, Vic. The Royal Australian College of General Practitioners. 2015. Available at: http://www.racgp.org.au/download/Documents/Guidelines/e-Mental%20health/e-mentalhealthguide.pdf [Accessed September 2017].
  32. Kuyken W, Hayes R, Barrett B, Byng R, Dalgleish T, Kessler D, et al. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. The Lancet. 2015; 386: 63-73.

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Key Points
  • Encourage all your DVA patients with depression to participate in psychological therapies
  • Avoid routinely starting patients with mild to moderate depression on an antidepressant
  • Tap into the DVA mental health resources that are available (see insert E-Mental health resources available to DVA patients)
  • Every six months re-evaluate the need for ongoing use of an antidepressant based on your patient’s individual circumstances