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Treating Depressionin the Primary Care SettingPharmacologic InterventionsPresented by: Jonathan Betlinski, MDDate: 09/25/2014
Disclosures and Learning Objectives
• Learning Objectives– Describe the Acute, Continuation and
Maintenance phases of MDD treatment– Know 3 ways to augment
antidepressants– Know 5 ways to address non-response
Disclosures: Dr. Jonathan Betlinski has nothing to disclose.
Depression in the Primary Care Setting
• Quick review of Screening for Depression
• Quick review of Nonpharmacology
• Pharmacological Treatment of Depression– Acute Phase– Continuation Phase– Nonresponse– Maintenance Phase
• Next Week's Topic
SIG E CAPS for Depression
S sleep decreased (or increased)
I interest decreased
G guilt or worthlessness
E energy decreased
C concentration difficulties
A appetite disturbance or weight loss
P psychomotor agitation or retardation
S suicidal thoughts
and depressed mood!
Treatment of Depression in Primary Care
Start all treatment with a medical work uphttp://www.nimh.nih.gov/health/publications/depression/index.shtml#pub6
Next comes Sleep Hygienewww.cci.health.wa.gov.au/docs/Info-sleep%20hygiene.pdf
And Exercisehttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3674785/pdf/nihms-386053.pdf
And Behavioral Activationwww.personal.kent.edu/~dfresco/CBT_Readings/BM_Lejuez_BATD_Manual.pdf
Antidepressants are no better than placebo for mild to moderate depressionhttp://medicine.plosjournals.org/archive/1549-1676/5/2/pdf/10.1371_journal.pmed.0050045-L.pdf
Pharmacology – Acute Phase
• Choose antidepressant based on– Prior response (individual or family)– Patient preference– Side effect profile– Safety in overdose– Availability and costs– Drug-Drug interactions– Impacts on co-morbid conditions
https://www.icsi.org/_asset/fnhdm3/Depr-Interactive0512b.pdf
Pharmacology – Acute Phase – Initial
• Most AD's are comparably effective• SSRI: citalopram, sertraline, fluoxetine,
escitalopram• SNRI: venlafaxine, duloxetine,
desvenlafaxine, • Mirtazapine (sedation, weight gain)• Bupropion (weight loss, nicotine cravings)http://psychiatryonline.org/pdfaccess.ashx?ResourceID=243261&PDFSource=6
https://www.icsi.org/_asset/fnhdm3/Depr-Interactive0512b.pdf
Pharmacology – Acute Phase – Next
• Titrate to an effective dose• Goal is a PHQ-9 of less than 5• Response may take 4-8 weeks• If side effects are too much, try lowering
the dose or switching.• Save MAOIs and TCAs for second linehttp://psychiatryonline.org/pdfaccess.ashx?ResourceID=243261&PDFSource=6
https://www.icsi.org/_asset/fnhdm3/Depr-Interactive0512b.pdf
Pharmacology – Nonresponse
• Reappraise diagnosis• Assess side effects• Assess comorbid conditions• Review psychosocial factors• Check treatment adherence• Check on psychotherapy progress• Consider medication switch vs. augmenthttp://psychiatryonline.org/pdfaccess.ashx?ResourceID=243261&PDFSource=6
https://www.icsi.org/_asset/fnhdm3/Depr-Interactive0512b.pdf
Pharmacology – Nonresponse - Changing
• Switch to another AD from same class• Switch to an AD from a different class
– Try an SNRI when SSRI not effective
• Augment with a different class AD– Augment with T3– Augment with lithium– Augment with a second-generation
antipsychotichttp://psychiatryonline.org/pdfaccess.ashx?ResourceID=243261&PDFSource=6
https://www.icsi.org/_asset/fnhdm3/Depr-Interactive0512b.pdf
Pharmacology – Continuation Phase
Continue Acute Phase treatment
For 4-9 months
Monitor regularly for recurrence
Use depression-focused psychotherapy to help prevent relapse (CBT)
Pharmacology – Maintenance Phase
Continue full therapeutic dose
Continue antidepressants indefinitely
For a complicated 2nd episode
For a third episode
For chronic depressionhttp://psychiatryonline.org/pdfaccess.ashx?ResourceID=243261&PDFSource=6
Monitor with PHQ-9 or WHO-DAShttp://www.who.int/entity/classifications/icf/WHODAS2.0_36itemsSELF.pdf?ua=1
Treating Depression in Primary Care
Depression is both common and treatable
PHQ-9 simplifies detecting and quantifying depression--and monitoring, too
The first steps in the treatment of recovery are usually nonpharmacological
Appropriate medications can be helpful
Treat to remission
The End!
Next Week's
Topic:
Assessing
Suicide
Risk