Download DEPRESSION IN PRIMARY CARE: An Overview

DEPRESSIONINPRIMARYCARE:
AnOverview
JorgeR.Petit,MD
QualityHealthSolutions
Topics In this Session
Overview
Clinical Importance of Depression
Types of Depression
Phases of Depression Care
Collaborative Care
Treatment Options
Considerations
 CLINICAL IMPORTANCE OF DEPRESSION
Depression is a chronic illness…
• It is a medical illness, not a character flaw
Imbalance of chemicals, similar to DM
• It causes a wide range of symptoms and behaviors
• It is common and treatable
Treatment may be long term, but is successful
Stigma negatively affects treatment
• It causes serious family/social ramifications
• Annual cost of untreated depression is more than $43.7 billion in absenteeism, lost productivity, and direct treatment costs.
Major Depressive Disorder
Major Depressive Disorder
Depression is a Chronic Disease
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Cumulative Probability of Recurrence
15 years after recovery  85% of patients have experienced a recurrence
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Years After Recovery
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Depression negatively affects health & well being…
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 medical morbidity, mortality, and disability
 suicide risk
 tobacco, alcohol, and/or drug use
 risk of MI, CVA, DM
 healthcare utilization
 adherence to treatments (medical and psychiatric)
 function (home and work)
Depression is common…
• 20-50% of patients with diabetes, CAD, Parkinson's,
CVA, HIV/AIDS, asthma, and cancer have major
depression:
– 15-23% of patients with MI develop major
depression
– 14-23% of patients with stroke develop major
depression
– 11-15% of patients with DM have major
depression
• Depressed patients visit their primary care provider
3xs more often than patients who are not
depressed.
Depression is under‐diagnosed and under‐treated
Local perspective…
• 2004 NYC HANES = 8%of New Yorkers had a diagnosis of depression at time of survey but only 37% were receiving clinically appropriate treatment.
Even though there are over 25 FDA‐approved antidepressant medications and other treatments available!
Depression is under‐diagnosed and under‐treated
• Almost 10% of the US population are taking antidepressants.
• According to the AHRQ = 170 million prescriptions filled for antidepressants in 2005 • 70% are prescribed by non‐psychiatrists (general practitioners, family practitioners and internal medicine specialists)
Depression is under‐diagnosed and under‐treated
• BUT…fewer than 50% are effectively treated
• Nearly ⅓ of antidepressant prescriptions are never filled.
• Nearly ½ of patients discontinue pharmacotherapy during the first month.
Antidepressant Adherence
100%
80%
• 1 mo  28% stopped
• 4 mo  44% stopped
60%
40%
20%
0%
0
1
2
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4
Months
Lin EH. Med Care 1995;33:67
Depression is under‐diagnosed and under‐treated
BUT treatment is effective…
• Over 30 – 50% of patients will have a complete response to initial treatment.
• 50 – 70% will require at least one change in treatment to get better.
 TYPES OF DEPRESSION Depressive Disorder
Depression
Primary
Secondary
Neuro
Unipolar
Bipolar
Cardiac
Sleep Apnea
Substance Use
Depressive Disorders
DSM 5 Depressive Disorders:
• Major Depressive Disorder
– Single episode
– Recurrent episode
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Persistent Depressive Disorder (Dysthymia)
Premenstrual Dysphoric Disorder
Substance/Medication‐Induced Depressive Disorder
Depressive Disorder Due to Another Medical Condition
Depressive Disorders
Diagnosis of Major Depressive Episode
Five (5) or more of the following symptoms present during the same 2‐week period and represent a change from previous functioning; at least one (1) of the symptoms is either depressed mood or loss of interest or pleasure. Symptoms must cause clinically significant distress or impairment in functioning.
Cannot be due to the direct effects of a substance (drugs or medications) or a medical condition, such as hypothyroidism, nor occur within two months of the loss of a loved one.
Depressive Disorders
1. Depressed Mood (most of the day, nearly every day) either by subjective report or observations made by others
2. Loss of interest or pleasure in activities
3. Significant weight loss when not dieting (<5% body weight in 1 month) or appetite changes (increased or decreased)
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive/inappropriate guilt
8. Decreased ability to think or concentrate, or indecisiveness
9. Recurrent thoughts of death or suicide
Depressive Disorders
Persistent Depressive Disorder
• Used to be called = Dysthymia
• Less severe, but more chronic
• Chronic “low grade” depression
Diagnosis 
• Depressed mood for most of the day, for more days that not (or irritability in children/adolescents) for at least 2 years (or 1 year in children/adolescents)
Depressive Disorders
Persistent Depressive Disorder
• Plus 2 additional symptoms while depressed:
– poor appetite or overeating
– insomnia or hypersomnia
– low energy or fatigue
– low self‐esteem
– poor concentration or difficulty making decisions
– feelings of hopelessness
• Never without symptoms for longer than 2 months at a time.
Depressive Disorder
Persistent Depressive Disorder
• Persistent Depressive Disorder affects approximately 1.5 percent of the U.S. population age 18 and older in a given year. • This figure translates to about 3.3 million American adults.
• The median age of onset of dysthymic disorder is 31.
Depressive Disorders
Bipolar Depression or Manic Depression
• Bipolar disorder ‐‐ sometimes referred to as manic depression ‐‐ is a complex mood disorder that alternates between periods of clinical depression and times of extreme elation or mania. • There are two subtypes of bipolar disorder: bipolar I and bipolar II.
– With bipolar I disorder, patients have a history of at least one manic episode with or without major depressive episodes.
– With bipolar II disorder, patients have a history of at least one episode of major depression and at least one hypomanic (mildly elated) episode.
Depressive Disorders
Adjustment Disorder [Now under the Trauma‐ and Stressor‐
Related Disorders Section]
• Adjustment disorder is a short‐term condition that occurs when a person is unable to cope with, or adjust to, a particular source of stress, such as a major life change, loss, or event. • People with adjustment disorders often have symptoms of depression, such as tearfulness, feelings of hopelessness, and loss of interest in work or activities, adjustment disorder is sometimes called "situational depression.” • Unlike major depression, however, an adjustment disorder is triggered by an outside stress and generally goes away once the person has adapted to the situation.
Other types…
Seasonal Depression (SAD) [with seasonal pattern]
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Seasonal depression, often called seasonal affective disorder or SAD, is a depression that occurs each year at the same time. It usually starts in the fall or winter and ends in spring or early summer. It is more than just "the winter blues" or "cabin fever." Psychotic Depression [with mood congruent or mood incongruent psychotic features]
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With psychotic depression, delusional thoughts or other symptoms of psychosis accompany the symptoms of depression. With psychotic depression, there's a break with reality. Patients with psychotic depression experience hallucinations and delusions.
Postpartum Depression [with peripartum onset]
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As many as 75% of new moms get the "baby blues." But about one in 10 moms develop a more serious condition called postpartum depression. According to NIMH, postpartum depression is diagnosed when a new mother develops a major depressive episode within one month after delivery.
 PHASES OF DEPRESSION CARE
Outcome Targets & Definitions
Clinically significant improvement (CSI)
5 point decrease in PHQ‐9 score
Response
50% decrease in PHQ‐9 score
Remission
PHQ‐9 score < 5 for 3 months
Patient Health Questionnaire (PHQ‐9)
9‐item, self administered questionnaire
Validated for diagnostic assessment
Validated for follow‐up of outcomes
Used to assess high‐risk, “red flag” patients
– Chronic illness
– Unexplained physical symptoms
– Appearing sad/stressed
– Loss of interest or pleasure
Patient Health Questionnaire (PHQ‐9)
Score indicates diagnosis and severity
• 0‐4: Not clinically depressed
• 5‐9: Mild depressive symptoms (adjustment disorder, dysthymic disorder)
• 10‐14: Mild/moderate symptoms (major depression; 88% sensitivity and specificity)
• >14: Moderate/severe depression (major depression; 95% specificity)
Discussing Diagnosis with Patient
• Don’t argue about whether or not patient has specific diagnosis focus on symptoms and symptom resolution
– Give hope!
– You don’t have to feel this way
– This can be treated
• Educate patient about treatment in primary care
– Depression / anxiety medical conditions
– Effective treatments available
Depression Clinical Practice Guidelines
Acute treatment phase
• Goal: Relieve symptoms, identify the right medication, optimize dose
• Duration: 1‐3 months
Continuation of therapy phase
• Goal: Resolve depressive episode, prevent relapse
• Duration: 4‐6 months
Long‐term maintenance phase
• Goal: Prevent relapse
• Duration: 3 months‐5 years depending on # of lifetime episodes and comorbid  COLLABORATIVE CARE Collaborative Care
Partnership between:
1) Primary Care Provider (PCP) and practice
2) Care Management
3) Collaborating Mental Health Specialist
Key features: • Integration of depression screening (and management) tools and routines into standard care
• Periodic quantitative feedback about the patient's response to treatment from the care manager to the clinician via the PHQ‐9 • Closer relationships between the primary care team and /behavioral health specialists, including informal psychiatric advice when needed from a psychiatrist
• The psychiatrist also provides weekly supervisory support for the care manager
Source: http://www.depression‐primarycare.org/organizations/component_model/
Evidence for CC Success
RESPECT – MacArthur Initiative
• Cluster randomized controlled trial • 60% response to treatment and 37% remission at 6 months, compared to 47% and 27% in usual care practices3
IMPACT Study
• Randomized clinical trial of collaborative care intervention for elderly patients
• Showed significant improvements in symptoms and functionality at 6 months, 12 months, and 2 years1
DIAMOND Initiative
• Adapted IMPACT program for general population setting and studied outcomes
• 64% response to treatment and 44% remission at 6 months; 72% response and 52% remission at 12 months2
Primary Care Provider Patient Registry
Screening/ Monitoring
Stepped Care
Approach
Care Manager
Consulting Psychiatrist
Relapse Prevention
The IMPACT Program: A team approach to depression care that gets dramatic results. John A. Hartford Foundation.
ICSI presentation, Oct. 2009.
3 Dietrich, A. et al., Re‐engineering systems for the treatment of depression in primary care: Cluster randomised controlled trial. British Medical Journal, 2004. doi: 10.1136/bmj.38219.481250.55.
1 2 Jaeckels, N. and Trangle, M. DIAMOND: Origin, Context & Future. Collaborative Care
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Partnership between primary care provider (PCP), care manager, and consulting psychiatrist
Integration of care manager and consulting psychiatrist into PCP‐based care team
Coordination of services and tracking progress carried out by care manager
Primary Care Provider
Care Manager
Psychiatrist
SCREEN all patients for depression ADVISE PCP on differential CONSULT by phone on difficult using the PHQ‐2
ASSESS all patients screening positive with the PHQ‐9
DIAGNOSE depression or other related condition if present
TREAT patients as indicated
cases re: differential diagnosis and treatment plan
REVIEW cases with team periodically
RECOMMEND assessment by psychiatrist as indicated
diagnosis and treatment plan EDUCATE patients/Behavioral Activation SUPPORT self‐management and medication adherence
ASSESS treatment progress with the PHQ‐9 COORDINATE referrals and care
services
 TREATMENT OPTIONS
Treatment Options During the Acute Phase
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Watchful Waiting
Psychotherapy
Antidepressant medication
Psychotherapy + medication
Treatment Option #1: Watchful Waiting
• Many depressions remit spontaneously
• Watchful Waiting is an acceptable “treatment plan”
• Initial treatment of choice for minor depression
• Variable intensity of Watchful Waiting
– Low (mild depression): repeat PHQ‐9 only
– Moderate (moderate depression): includes behavioral goals (e.g., exercise)
Treatment Option #2: Psychotherapy
• Effective in:
– Mild to moderate depression
– Adjunct to antidepressants
• Not effective (as 1st line) in:
– Severe depression
• Barriers
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Previous negative experience
Nervous about first counseling experience
Worried about stigma
Family has negative bias
Believes counseling is not helping
Treatment Option #3: Pharmacotherapy
• Effective in:
– Major depressive Disorder
– Chronic depression
• Not recommended for:
– Minor depression
• Barriers
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Beliefs (e.g.,“Medicine can’t help feelings”)
Stigma (e.g., “I should be able to do this myself”)
Cost
Family has negative bias
Acute Phase: Medication Guidelines
• Elicit patient commitment (i.e., personal action plan)
• Start with SSRI (citalopram) or new agent
• Arrange early follow‐up after initial visit (within 1‐3 weeks)
• Repeat PHQ‐9 at every follow‐up (every 1‐2 months)
• Increase dose of antidepressant every 2‐4 weeks up to maximum dose or until remission
Sources: www.ahrq.gov; www.depression‐primarycare.org; American Psychiatric Association
Continuation Phase
• After Acute Phase, assess treatment response at every follow‐up:
If response is adequate (patient achieves full remission):
Continue follow‐up with PHQ‐9 administration and treatment
Form relapse prevention plan
If response is inadequate (partial or no response):
Consult psychiatrist
Formulate secondary treatment plan and implement with psychiatric oversight (as needed)
Sources: www.ahrq.gov; www.depression‐primarycare.org; American Psychiatric Association
Continuation Phase • Continuation therapy is intended to prevent relapse, that is, to suppress the symptoms of a current depressive episode from which the patient has not fully recovered. • Usually, continuation therapy lasts 4 to 6 months after a patient has responded in the acute phase of treatment.
• After completion of Continuation Phase, consider maintenance treatment
Preventing Recurrence
Risk of recurrence becomes more likely with each episode of depression
• > 50% after 1st recurrence
• 70% after 2nd recurrence
• 80‐90% after 3rd recurrence
1 Judd LL et al. Am J Psychiatry, 2000; 157:1504‐1504.
2 Mueller TI et al. Am J Psychiatry, 1999; 156:1000‐1006.
3 Frank E et al. Arch Gen Psychiatry, 1990; 47:1093‐1099.
Preventing Recurrence
If patient’s response to treatment is insufficient, or does not respond at all:
Assess adherence
Re‐evaluate diagnosis
Adjust dosage
Change/augment antidepressant
Consider switch to or add dual action agent
Consider psychotherapy
Refer for expert consultation
Discussing Treatment Options
• Review all treatment options available
– Psychotherapeutic interventions
• Behavioral Activation, Problem‐Solving Treatment, Cognitive‐Behavioral Treatment, etc.
– Medications
• Discuss pros and cons of each option
Discussing Treatment Options
• The treatment that WORKS is the best one
– Person‐centered care means selecting treatments based on client preference, not clinician preference
• Be unbiased when offering treatment options
– Be eclectic: “One size fits few”
• Supporting whole person treatment is important
– This may include medication therapy
• You can support medication therapy within scope of practice
• Ask questions and collect information
• Support patient being informed and active in plan
Non‐Medication Treatment Options
• Support
• Self Management/Wellness – Activity Scheduling (pleasant activities)
– Physical activity / exercise
• Psychotherapies
– Cognitive‐behavioral therapy (CBT)
– Problem‐solving Treatment (PST)
– Interpersonal psychotherapy
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Individual
Group
Family
Marital/Couples
Pharmacotherapy
• Prior response and/or treatment history in patient/ family members
• Patient preferences
• Expertise of prescribing provider
• Side effect profile
• Safety in overdose: 10 days of a TCA can be a lethal overdose
• Availability and costs
• Drug‐drug interactions
Pharmacotherapy
Key principles 
• Use adequate doses for an adequate amount of time.
• Start slow and work with side effects but titrate to an effective dose as needed.
• Change medication if not effective
– Usually after 8 – 10 weeks
• Current evidence does not warrant the choice of one second‐generation AD over another on the basis of differences in efficacy and effectiveness. – Other differences with respect to onset of action and adverse events may be relevant for the choice of a medication. Antidepressants
• SSRIs
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Citalopram (Celexa®)
Escitalopram (Lexapro®)
Fluoxetine (Prozac®)
Fluvoxamine (Luvox®)
Paroxetine (Paxil®)
Sertraline (Zoloft®)
• SNRIs
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Duloxetine (Cymbalta®)
Venlafaxine (Effexor XR®)
Desvenlafaxine (Pristiq®)
Levomilnacipran ER (Fetzima®)
• Mirtazapine (Remeron®)
• Bupropion (Wellbutrin®)* Antidepressants
• Trazodone (Oleptro®) and Nefazadone (Serzone®)
• TRICYCLICS and TETRACYCLICS
– Desipramine (Norpramin®)
– Nortryptaline (Pamelor®)
• MAOIs
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Phenelzine (Nardil®)
Tranylcypromine (Parnate®)
Isocarboxazid (Marplan®)
Selegeline (Eldepryl®)
• Vilazadone (Viibyrd®)
• Vortioxetine (Brintellix®)  CONSIDERATIONS
Considerations: Side Effects
Short term:
– GI upset / nausea
– Jitteriness / restlessness / insomnia
– Sedation / fatigue
Long term:
– Sexual dysfunction (up to 33%)
– Weight gain (5 to 10%)
Considerations: Side Effects
• Common side effects in all SSRIs (>10 %): GI distress (nausea, diarrhea),insomnia, restlessness, agitation, fine tremor, headache, dizziness, sexual dysfunction.
• SNRI side effects: GI distress (nausea, diarrhea), insomnia, restlessness, agitation, fine tremor, headache, dizziness, constipation, decreased appetite, sexual dysfunction. – Small risk of elevation of blood pressure at higher doses => check BP.
Considerations: Side Effects
Consult with pharmacist / team psychiatrist
– Are side effects ‘physical’ or ‘psychological’?
Short term strategies
– Wait and support (e.g., GI side effects of SSRIs)
– Adjust medication timing (e.g., take sedating meds at bedtime)
– Consider temporary dose reduction
– Treat side effects (if drug effective)
Change to a different antidepressant
Change to or add PST‐PC
Considerations: Side Effects
Activating…
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Fluoxetine (Prozac®)
Citalopram (Celexa®)
Sertraline (Zoloft®)
Venlafaxine (Effexor®)
Bupropion (Wellbutrin®)
Sedating…
• Paroxetine (Paxil®)
• Fluvoxamine (Luvox®)
• Mirtazepine
(Remeron®)
• Nefazadone (Serzone®)
• Trazadone
Considerations: Discontinuation Syndrome
• Most frequent with paroxetine (short elimination ½ life and no active metabolite) • Least frequent with fluoxetine (long ½ life of parent compound and active metabolite)
• Physical Symptoms = dizziness, nausea, vomiting, lethargy, fatigue, flu‐like symptoms (aches, chills), sleep disturbance
• Psychological Symptoms = anxiety, irritability
• Emerges 1 – 3 days after discontinuation
• IMPORTANT = slow taper of short acting agents
Considerations: Black Box Warning
FDA public health advisory in 2004 and then Black Box Warning re: increased suicidality risk in children, adolescents and young adults < 25 years old
Management:
• Depression associated with increased suicide risk
• Suicide assessment warranted if Question 9 on PHQ is scored
• Weigh risk vs. benefit
• Observe all patients for clinical worsening
Considerations: Orgasmic Dysfunction
• 25 – 33% of SSRI‐treated patients
• Change to…
– Bupropion
– Mirtazapine
• Augment with…
– Bupropion SR 100mg PO BID
– Buspirone 15mg PO BID to 30mg PO BID
Considerations: Problems Early in Treatment
• Non‐adherence
• Medical and psychiatric comorbidity
• Side effects
• Unmasking bipolar disorder
• Activation and suicidal ideation
• Incomplete response
Considerations: What if Patients Don’t Improve?
Is the patient adhering to treatment?
Is the dose high enough?
– See max dose guidelines
Is the diagnosis correct?
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? Bipolar depression
? Medical conditions (hypothyroidism, sleep apnea, pain)
? Meds: steroids, interferon, hormones
? Withdrawal: stimulants, anxiolytics
Are there untreated comorbid conditions / life stressors?
Medication Adherence
• 20% to 30% medication prescriptions never filled consistently
• Medication not continued as prescribed in about 50% of cases, especially long term therapies • Rates of medication adherence drop after first six months • Only 51% of Americans treated for hypertension are adherent to their long‐term therapy • About 25% to 50% of patients discontinue statins within one year of treatment initiation
Determinants
Provider Factors
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Communication skills
Knowledge of health literacy issues
Lack of empathy
Lack of positive reinforcement Number of comorbid conditions
Number of medications needed per day
Types or components of medication Amount of prescribed medications or
duration of prescription
Determinants
Patient‐related
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Physical Psychological Condition‐ and therapy‐related
• Complexity of medication • Frequent changes in regimen • Treatment requiring mastery of certain techniques • Unpleasant side effects • Duration of therapy • Lack of immediate benefit of therapy • Medications with social stigma
Determinants Economic • Health insurance
• Medication cost
Social • Limited English proficiency • Inability to access or difficulty accessing pharmacy • Lack of family or social support • Unstable living conditions
What Can you Do to Overcome These Challenges? • Communication is key! • Effective interventions • Measure medication adherence
General Office Strategies for Optimizing Adherence
Provide rationale for use
Careful attention to side‐effects Address fear of dependence and loss of control
Enlist family/spousal support
Address concerns in relation to patient’s or significant other’s prior experience with medication
• Increase contact with brief phone check‐ins
• Specific instructions (take regardless of symptom change, don’t stop on own)
• Use symptom scale (e.g., PHQ‐9)
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Interventions
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Simplify the regimen
Impart knowledge
Modify patient beliefs and behavior
Provide communication and trust
Leave the bias
Evaluate adherence
S—Simplify the Regimen
• Adjust timing, frequency, amount, and dosage
• Match regimen to patient’s activities of daily living • Recommend taking all medications at the same time of day • Avoid prescribing medications with special requirements • Investigate customized packaging for patients
• Encourage use of adherence aids
• Consider changing the situation vs. changing the patient I—Impart Knowledge
• Focus on patient‐provider shared decision making • Keep the team informed (physicians, nurses, and pharmacists)
• Involve patient’s family or caregiver if appropriate
• Advise on how to cope with medication costs • Provide all prescription instructions clearly in writing and verbally • Suggest additional information from Internet if patients are interested • Reinforce all discussions often, especially
for low‐literacy patients M—Modify Patient Beliefs and Behavior
• Empower patients to self‐manage their condition • Ensure that patients understand their risks if they don’t take their medications • Ask patients about the consequences of not taking their medications • Have patients restate the positive benefits of taking their medications • Address fears and concerns • Provide rewards for adherence P—Provide Communication and Trust •
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Improve interviewing skills Practice active listening
Provide emotional support Use plain language Elicit patient’s input in treatment decisions L—Leave the Bias • Understand health literacy and how it affects outcomes • Examine self‐efficacy regarding care of racial, ethnic, and social minority populations • Develop patient‐centered communication style • Acknowledge biases in medical decision making • Address dissonance of patient‐provider, race‐ethnicity, and language E—Evaluating Adherence
• Self‐report • Ask about adherence behavior at every visit
• Periodically review patient’s medication containers, noting renewal dates • Use biochemical tests—measure serum or urine medication levels as needed • Consider using medication adherence
Key Educational Messages for Patients
Antidepressants only work if taken every day
Antidepressants are not addictive
Benefits from medication appear slowly
Continue antidepressants even after you feel better
Mild SE are common and usually improve over time
If you’re thinking about stopping the medication, call me first
• The goal of treatment is to complete remission; sometimes it takes a few tries
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Is Patient at Maximum Therapeutic Dosage?
Fluoxetine
Paroxetine
Escitalopram
Citalopram
Sertraline
Venlafaxine
Desvenlafaxine
Duloxetine
Bupropion SR
Mirtazapine
Nortriptyline
Despramine
60mg
60mg
20mg
60mg
200mg
300mg
100 mg
60mg
450mg
60mg
125mg (check serum level)
200mg (check serum level)
Good Reasons to Stop a Medication
• Intolerable side effects
• Dangerous interactions with necessary medications
• The medication was not indicated to start with (e.g., bipolar depression)
• Medication has been at maximum therapeutic dose without improvement for 4‐8 weeks
Dose Increase: Practical Approaches
• Definition = use of doses higher than those considered standard for a given antidepressant
• Rationale – Increase chance of obtaining adequate blood levels in rapid metabolizers
– Obtain a different neurochemical effect (e.g.: going from relatively selective serotonergic effect at lower doses to a dual action effect at higher doses)
Dose Increase: Practical Approaches
• Gradual increasing the dose by 50‐100%
• Wait at least 4 weeks before deciding whether the strategy works
• If no side effects are present, consider increasing further
• Blood levels may be informative (even with SSRIs or other newer agents)
Switching: Practical Approaches
• Gradual taper one agent while starting new one
– Side effects of new drug may be intensified by the concurrent presence of 1st agent
– “Start low and go slow” with new agent
– Consider possible drug‐drug interactions
• Wash‐outs are necessary with MAOIs
Antidepressant Summary
There are over 25 FDA‐approved antidepressants
– Each is effective in ~ 40 – 50% of patients
– It may take several trials until an effective medication is identified
– Patients need support during this time (work with care manager)
Antidepressant Summary
If medications are not effective after 8 – 10 weeks at a therapeutic dose
– Is patient taking medication as prescribed?
– Consider substance abuse, bipolar disorder, anxiety disorders, cognitive impairment. Ask every patient about suicidal ideation
– Consult with team psychiatrist and change treatment (medications, other somatic treatments, psychotherapy)