initiation of antidepressants in primary caresnapaprn.org/pdfs/initiation of antidepressants in...
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Avoiding
Potentially
Dangerous
Treatment
Delays
INITIATION OF
ANTIDEPRESSANTS IN
PRIMARY CARE
Define Depressive Disorders
Identify Useful Screening Tools
Identify When to Initiate Antidepressants
Distinguish Between Types of Antidepressants
to Predict & Evaluate Efficacy
OBJECTIVES
Strive to be a healer, not a
technician.
Allan Peterkin, MD
DSM IV-TR (2000)
Major Depressive Disorder
Single Episode (296.2x)
Recurrent (296.3x)
Mild, Moderate, Severe without & with psychotic
features, Partial & Full Remission
Coded 296.x1-6
DEPRESSIVE DISORDERS
5 or more symptoms present in same 2 -week period, a change
in previous functioning, at least 1 is depressed mood or loss
of interest/pleasure
Not mixed with manic symptoms
Cause clinically significant distress/impaired functioning
Not due to substances, general medical condition, grief
Marked preoccupation with worthlessness, suicidal ideation,
psychotic symptoms, psychomotor retardation
MAJOR DEPRESSIVE DISORDER
Depressed mood most days: sad, empty, irritable
Marked loss of interest or pleasure
Weight loss when not dieting, e.g. >5% in a month
Insomnia or Hypersomnia
Psychomotor retardation or agitation, observable by others
Fatigue or loss of energy
Feelings of worthlessness or guilt
Difficulty concentrating, or indecisiveness
Recurrent thoughts of death, suicidal ideation
With or without plan
WE MUST ASK
SPECIFIC DEPRESSIVE SYMPTOMS
DSM IV-TR
Dysthymic Disorder (300.4)
Chronic, less severe depressive symptoms
Present for many years
DEPRESSIVE DISORDERS
DSM IV-TR
Substance-Induced Mood Disorder (292.84)
Mood Disorder NOS (296.90)
Mood Disorder Due to General Medical Condition
(293.83)
INCREASES RISK OF SUICIDE
DEPRESSIVE DISORDERS
Rates vary depending on specific condition
Chronic, incurable, painful conditions carry
the greatest risk
WE MUST ASK
SUICIDE
& GENERAL MEDICAL CONDITIONS
DSM 5 (2013 – due out in May)
Disruptive Mood Dysregulation Disorder (previously described as Pediatric Bipolar D/O
Premenstrual Dysphoric Disorder
>5 of 12 months, 1 week before menses
Mixed Anxiety/Depression
At least 3 symptoms of MDD or GAD
Major correlate to suicidal thoughts
DEPRESSIVE DISORDERS
Dystonic: Patient is aware & in pain
Severe impairment in functioning
Correlation to drug use, especially EtOH,
amphetamines, cocaine
Powerful correlate to suicide
DSM 5 DEPRESSIVE DISORDERS
Wide Variety
Clinician vs Client/Self Rating
Time Involved: 2-30 minutes
Public Domain vs Copyrighted
Realistic Application: Valid & Brief
SCREENING TOOLS
Choosing a Rating Scale
Consider your Population
Scale Validity & Reliability
Assessing what it’s designed to assess
Ability to provide consistent, reproducible info
Available Staff Resources, Time, Training
Scale Standardization
Ease of Participation by Patient
SCREENING TOOLS
Hamilton Rating Scale for Depression (HAM-D, 1960)
17-31 items, public, 30 minutes
Beck Depression Inventory (BDI, 1961; BDI -II , 1993)
21 items, copyright, 5-10 minutes
Montgomery -Asberg Depression Rating Scale (MADRS, 1979)
10 items, public, 20 minutes
Raskin-Covi Scales (1969, 1981)
6 items, public, several minutes
Mood Disorder Questionnaire (MDQ, 2000)
13 items, public, 5-10 minutes, screens for Bipolar Disorder
SCREENING TOOLS
Examples Included
Raskin-Covi Scales
Observer Rated
Severity score used in pharmacologic study
outcome
MADRS
Observer Rated
Does not cover somatic or psychomotor symptoms
as fully as HAM-D
SCREENING TOOLS
Make even your first
assessment a therapeutic
experience for the patient. One
encounter may actually be
enough or all the patient can
afford right now.
Allan Peterkin, MD
WHEN MIGHT IT BE NECESSARY TO
INITIATE ANTIDEPRESSANTS
You may be the First & Only Provider
(Un)Availability or (Un)Desirability of
Psychiatric Providers
Severity of symptoms vs Time delay
?
Important Considerations
Patient has significant distress/impaired function
Patient has no capacity to cope with problem
Patient is motivated for treatment
Patient has thoughts or intentions of suicide
Consider in-patient referral
WHEN MIGHT IT BE NECESSARY TO
INITIATE ANTIDEPRESSANTS?
Additional Important Considerations
Less risk than long-term Benzodiazepine use
Discuss Black Box Warnings
Discuss risk of mania if Bipolar D/O is possible
Serotonin Syndrome potential
Consider non-psychiatric drugs patient takes
WHEN MIGHT IT BE NECESSARY TO
INITIATE ANTIDEPRESSANTS?
Why are there so many different
antidepressant drugs?
Why is the efficacy so unpredictable?
Consider: There are 3 known Serotonin
receptor genes
TYPES OF ANTIDEPRESSANT DRUGS-
PREDICTING & EVALUATING EFFICACY
Monoamine Oxidase Inhibitors
Example: Parnate (Tranylcypromine)
Indications: Refractory Depression
Dosing: 30 mg/day, divided; max 60 mg/day
Concerns: Numerous
Hypertensive Crisis w/ sympathomimetics, levo-dopa, high-tyramine foods e.g. cheese, chocolate, yogurt, wine, beer
Must stop other drugs 1-5 weeks before use
Less problematic with transdermal EMSAM
TYPES OF ANTIDEPRESSANT DRUGS –
PREDICTING & EVALUATING EFFICACY
Tricyclics
Example: Elavil (Amitriptyline)
Indications: Depression, especially endogenous; also used in pain management
Dosing: 10-75 mg/day; max 150 mg/day
Concerns: Numerous
Hyperpyretic crisis w/ MAOIs, anticholinergics, sympathomimetics
Paralytic ileus w/ anticholinergics
Arrhythmias
Galactorrhea
TYPES OF ANTIDEPRESSANT DRUGS-
PREDICTING & EVALUATING EFFICACY
Tricyclics
Example: Tofranil (Imipramine)
Indications: Depression; off-label nocturnal enuresis
Dosing: 10-75 mg/day; max 200 mg/day
Concerns: Numerous
Urinary retention
Hyperpyretic crisis, convulsions, death w/ MAOIs
Arrhythmias
EPS
TYPES OF ANTIDEPRESSANT DRUGS-
PREDICTING & EVALUATING EFFICACY
Serotonin Specific Reuptake Inhibitors
Example: Prozac (Fluoxetine)
Indications: MDD, Bulimia nervosa, Panic D/O, OCD
Dosing: 10-60 mg/day; max 80 mg/day
Concerns: Suicidal Ideation Warning
Long half-life
Increased risk of bleeding with drugs that affect coagulation (menorrhagia even w/o these)
Serotonin Syndrome (weakness, incoordination, hyper-reflexia, tachycardia, confusion, agitation)
Sexual side effects
TYPES OF ANTIDEPRESSANT DRUGS-
PREDICTING & EVALUATING EFFICACY
SSRIs
Example: Paxil (Paroxetine)
Indications: Depression, PMDD, Social Anx D/O, Panic D/O
Dosing: 10-40 mg/day; max 50 mg/day
Concerns: Suicidal Ideation Warning
Highly protein bound
Serotonin syndrome
Abnormal bleeding
Sexual side effects
TYPES OF ANTIDEPRESSANT DRUGS-
PREDICTING & EVALUATING EFFICACY
SSRIs
Example: Zoloft (Sertraline)
Indications: Depression, PMDD, Panic D/O, PTSD,
OCD, Social Anxiety D/O
Dosing: 25-100 mg/day; max 200 mg/day
Concerns: Suicidal Ideation Warning
Serotonin Syndrome
Diaphoresis
Sexual side effects
TYPES OF ANTIDEPRESSANT DRUGS-
PREDICTING & EVALUATING EFFICACY
SSRIs
Example: Lexapro (Escitalopram)
Indications: MDD, GAD
Dosing: 5-20 mg/day; max 20 mg/day
Concerns: Suicidal Ideation Warning
Serotonin Syndrome
Abnormal bleeding
Interacts with Tramadol
Sexual side effects
TYPES OF ANTIDEPRESSANT DRUGS-
PREDICTING & EVALUATING EFFICACY
SSRI + 5-HT1A Receptor Partial Agonist
Viibryd (Vilazodone)
Indications: MDD
Dosing: 10-40 mg/day; max 40 mg/day
Concerns: Suicidal Ideation Warning
Highly protein bound
Abnormal bleeding
Serotonin Syndrome with concomitant drugs, but less likely as partial agonist takes place of 5-HT that’s been inhibited
TYPES OF ANTIDEPRESSANT DRUGS-
PREDICTING & EVALUATING EFFICACY
Serotonin-Norepinephrine Reuptake Inhibitors
Example: Effexor (Venlafaxine)
Indications: MDD, GAD, Social AnxD/O, Panic D/O
Dosing: 37.5-225 mg/day; max 375 mg/day
Concerns: Suicidal Ideation Warning
Hypertension
Serotonin Syndrome
Abnormal bleeding
Severe discontinuation sx, e.g. paresthesia, tremor, GI, agitation (titrate extremely slowly)
TYPES OF ANTIDEPRESSANT DRUGS-
PREDICTING & EVALUATING EFFICACY
SNRIs
Example: Pristiq (Desvenlafaxine)
Indications: MDD; in trials for “Hot Flashes”
Dosing: 50-100 mg/day; max 100 mg/day
Concerns: Suicidal Ideation Warning
Possible Hypertension
Serotonin Syndrome
Hyperhidrosis, mydriasis
Can give 50mg qod in ESRD
TYPES OF ANTIDEPRESSANT DRUGS-
PREDICTING & EVALUATING EFFICACY
SNRIs
Example: Cymbalta (Duloxetine)
Indications: MDD, GAD
Dosing: 20-60 mg/day; max 120 mg/day
Concerns: Suicidal Ideation Warning
Highly protein bound
Possible Hypertension
Hepatotoxicity, avoid w/ excessive EtOH use
TYPES OF ANTIDEPRESSANT DRUGS-
PREDICTING & EVALUATING EFFICACY
Other Classes
Example: Wellbutrin (Bupropion)
Indications: Depression, Seasonal Affective D/O
Dosing: 75-300 mg/day; max 450 mg/day
Concerns: Suicidal Ideation Warning
Increased seizure risk, especially >300mg/day
If seizure occurs, D/C & do not restart
If b.i.d. dosing, give 8 hrs apart & last dose by 5pm
Possible Hypertension w/ nicotine replacement
TYPES OF ANTIDEPRESSANT DRUGS-
PREDICTING & EVALUATING EFFICACY
Other Classes
Example: Remeron (Mirtazapine)
Indications: MDD, off-label appetite & sleep aid
Dosing: 7.5-45 mg/day; max 45 mg/day
Concerns: Suicidal Ideation Warning
Serotonin Syndrome
Possible fatal reactions with MAOIs
Dose at HS
7.5 mg dose-most SE increasing appetite & sleep
TYPES OF ANTIDEPRESSANT DRUGS-
PREDICTING & EVALUATING EFFICACY
Other Classes
Example: Desyrel (Trazodone)
Indications: Depression
Dosing: 25-300 mg/day; max 600 mg/day (inpt)
Concerns: May affect anticoagulants
Drowsiness, dizziness, hypotension
Headache
Potentiates EtOH, other CNS depressants
Most often used in lower doses for sleep aid
TYPES OF ANTIDEPRESSANT DRUGS-
PREDICTING & EVALUATING EFFICACY
Antiepileptics
Examples: Depakote, Lamictal, Trileptal, Topamax
Antipsychotics
Examples: Abilify, Geodon, Risperdal, Seroquel, Zyprexa, Symbyax (Olanzapine/Fluoxetine)
Lithium
Used as Mood Stabilizers
May be essential to effectively treat Bipolar D/O
ADJUNCT THERAPY
You are seldom helping
only the patient in front of
you.
You are helping their
partners, children,
employees, and friends.
Allan Peterkin, MD
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4 th ed.), Text Revision. Washington, DC: APA.
Ernst, D. (Ed.). (2012). Mood disorders, Anxiety/OCD. Nurse Practitioners’ Prescribing
Reference, 19 (4).
Klott, J. (2012). Revolutionizing diagnosis & treatment using the DSM -5. Eau Claire, WI: CMI
Education Institute.
Mullen, J. (Ed.). (2004). Manual of rating scales for the assessment of mood disorders.
Wilmington, DE: AstraZeneca Pharmaceuticals, LP.
Peterkin, A. (1999). The psychiatrist’s little book of wisdom: 350 tips and reflections on
clinical practice and the art of communicating. Royal Oak, MI: Physicians’ Press.
REFERENCES