Download Initiation of Antidepressants in Primary Care

INITIATION OF
ANTIDEPRESSANTS IN
PRIMARY CARE
Avoiding
Potentially
Dangerous
Treatment
Delays
OBJECTIVES
Define Depressive Disorders
Identify Useful Screening Tools
Identify When to Initiate Antidepressants
Distinguish Between Types of Antidepressants
to Predict & Evaluate Efficacy
Strive to be a healer, not a
technician.
Allan Peterkin, MD
DEPRESSIVE DISORDERS
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
MAJOR DEPRESSIVE DISORDER
 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
SPECIFIC DEPRESSIVE SYMPTOMS
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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
Dif ficulty concentrating, or indecisiveness
Recurrent thoughts of death, suicidal ideation
 With or without plan
 WE MUST ASK
DEPRESSIVE DISORDERS
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
SUICIDE
& GENERAL MEDICAL CONDITIONS
Rates vary depending on specific condition
Chronic, incurable, painful conditions carry
the greatest risk
WE MUST ASK
DEPRESSIVE DISORDERS
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
DSM 5 DEPRESSIVE DISORDERS
Dystonic: Patient is aware & in pain
Severe impairment in functioning
Correlation to drug use, especially EtOH,
amphetamines, cocaine
Powerful correlate to suicide
SCREENING TOOLS
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
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

WHEN MIGHT IT BE NECESSARY TO
INITIATE ANTIDEPRESSANTS?
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
T YPES OF ANTIDEPRESSANT DRUGSPREDICTING & EVALUATING EFFICACY
Why are there so many different
antidepressant drugs?
Why is the efficacy so unpredictable?
Consider: There are 3 known Serotonin
receptor genes
T YPES 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, levodopa, high-tyramine foods e.g. cheese, chocolate,
yogurt, wine, beer
 Must stop other drugs 1-5 weeks before use
 Less problematic with transdermal EMSAM
T YPES OF ANTIDEPRESSANT DRUGSPREDICTING & 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
T YPES OF ANTIDEPRESSANT DRUGSPREDICTING & 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
T YPES OF ANTIDEPRESSANT DRUGSPREDICTING & 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, hyperreflexia, tachycardia, confusion, agitation)
 Sexual side effects
T YPES OF ANTIDEPRESSANT DRUGSPREDICTING & 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
T YPES OF ANTIDEPRESSANT DRUGSPREDICTING & 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
T YPES OF ANTIDEPRESSANT DRUGSPREDICTING & 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
T YPES OF ANTIDEPRESSANT DRUGSPREDICTING & EVALUATING EFFICACY
SSRI + 5-HT 1A 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
T YPES OF ANTIDEPRESSANT DRUGSPREDICTING & 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)
T YPES OF ANTIDEPRESSANT DRUGSPREDICTING & 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
T YPES OF ANTIDEPRESSANT DRUGSPREDICTING & 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
T YPES OF ANTIDEPRESSANT DRUGSPREDICTING & 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
T YPES OF ANTIDEPRESSANT DRUGSPREDICTING & 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
T YPES OF ANTIDEPRESSANT DRUGSPREDICTING & 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
ADJUNCT THERAPY
 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
You are seldom helping
only the patient in front of
you.
You are helping their
partners, children,
employees, and friends.
Allan Peterkin, MD
REFERENCES
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.