In episode 18 we consider the approach to questions of bone density and fracture risk. We use a series of cases to work through the risk of osteoporosis (using a simple tool) and help us decide on bone mineral density testing. We discuss initial options in the prevention of fractures including weight-bearing exercise, Calcium and Vitamin D (and its additional advantages).

Show Notes

1) Osteoporosis self-assessment tool – estimating risk of osteoporosis

2) Vitamin D and Calcium (for fracture)

3) Vitamin D and falling risk

JAMA 2004;291:1999-2006

4) Meta-analysis of Vit D on Mortality

Arch Intern Med 2007;167:1730-1737

In episode 17 we look at managing the treatment of depression once we’ve started a medication. We discuss the patient conversations necessary for initiating treatment including the patient perception of the illness, expectations and potential side-effects. We debate the quandaries around starting doses, when or if to increase, duration of therapy and relapse prevention. Although we use available evidence, we acknowledge some of our advice is Best-Guess based medicine.

Show Notes

1) Monitoring form for using antidepressants in children and adolescents

2) Clinical tool to monitor antidepressant treatment

3) Scales, doctors finding benefit (when there isn’t any)

Lancet 2004;363:1341-5

4) Investigators’ conclusions on the efficacy of newer antidepressants in childhood depression have exaggerated their benefits

BMJ 2004;328:879-83

5) Benefit seen in 1 week with antidepressants

Arch Gen Psychiatry 2006;63:1217-23

6) The risk of recurrence progressively increases with each successive episode and decreases as the duration of recovery increases

Am J Psychiatry 2000;157:229–233)

7) Relapse due to stopping meds – relapse at 12 months – 18% on drugs 41% on placebo

Lancet 2003;361:653–51

8) 5mg of fluoxetine works Psychopharmacology Bulletin 1988;24:183-8

Click here to download article

In episode 16 we look at initiating treatment for depression. We briefly review screening and the diagnosis of depression before discussing the non-drug treatment options (therapy, exercise, sleep hygiene). We search for the anti-depressant of choice (being any) and end up deciding to tailor the choice based on factors such as side-effect profile, targeted symptoms, and cost. Although we stress the importance of regular follow-up, James refuses to come to see Mike or Adil.

Show Notes

1) Two screening questions for depression – do you feel depressed, do you have little interest in doing things

BMJ 2003; 327:1144-46

J Gen Intern Med. 1997;12:439-45

2) Benefit seen in 1 week with antidepressants

Arch Gen Psychiatry 2006;63:1217-23

3) No difference between the second generation antidepressants in effect

Ann Intern Med. 2005;143 :415-26

4) Weight benefit with fluoxetine.

Arch Intern Med 2004;164:1395-1404

5) Amitriptyline is as effective as other tricyclics or newer agents

Cochrane Library

6) Monitoring form for using antidepressants in children and adolescents

7) Clinical tool to monitor antidepressant treatment

In episode 15 a guest assists us in addressing the evidence suggesting anti-depressants are not as effective as believed. We review some biases in the anti-depressant research including publication bias (how good studies are published more than bad studies). We discuss how the benefits of anti-depressants over placebo increase as the severity of depression worsens. James prompts us to explain the effectiveness of the medications; although we dodge, some vague commitments do manage to escape.

Show Notes

1) Selective publication of selective serotonin reuptake inhibitors data

BMJ 2003;326:1171-73

2) Another select report on the selective publication of selective serotonin reuptake inhibitors

NEJM 2008; 358: 252

3) Antidepressants have a clinically important effect above placebo only in patients with severe depression

PLOS 2008:5(2):0260-8

4) Fluoxetine – evidence for benefit in children – others maybe not?

Lancet 2004;363:1341-5

5) In children, with antidepressants, the magnitude of benefit is unlikely sufficient to justify the harms

http://www.bmj.com/cgi/content/full/328/7444/879