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Getting the Most of Antidepressants RVU 05-03-2014. Larry O. Sanders, MD Diplomate of the American Board of Psychiatry and Neurology. Goals. Screening the Primary Care population for Mental Disease. First Line and Second Line Treatment of MDD.

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getting the most of antidepressants rvu 05 03 2014
Getting the Most of AntidepressantsRVU 05-03-2014
  • Larry O. Sanders, MD
  • Diplomate of the American Board of Psychiatry and Neurology
goals
Goals
  • Screening the Primary Care population for Mental Disease.
  • First Line and Second Line Treatment of MDD.
  • Evidence that more than Major Depression is Involved.
  • When to Refer to Mental Health.
why treat depression
Why Treat Depression?
  • Disability
  • Morbidity- Depression makes existing somatic conditions worse. (Inflammatory Factors)
  • Mortality- Psychiatric patients die up to 20years earlier than average. Most Common reason is Cardiovascular Disease!
    • Second is Suicide.
inflammatory factors 1
Inflammatory Factors, 1
  • Major Depression Increases
  • Inflammatory Factors,
  • Worsening the Prognosis of
  • Somatic Illness
inflammatory factors 2
Inflammatory Factors, 2
  • Somatic Illnesses
  • Increase
  • Inflammatory Factors,
  • Worsening the Prognosis of
  • Major Depression
slide8

Depression and Atherosclerotic Disease.

  • Major Depression carries 4X Riskof developing a Myocardial Infarction! Anda 1993, Barefot, et. Al. 1996, Pratt 1996
  • MIs comorbid with MDD are 5X More likely to be Fatal.Anda 1993
  • 16.5% Mortality [email protected] 6 months following Acute MI if also Depression vs 3% if not Depressed.Frasure-Smith 1993
  • Major Depression carries same Risk Factor for developing an MI, as Cigarette Smoking!
major depression 5 symptoms 2 weeks 50 each day
Major Depression5 Symptoms, 2 Weeks, >50% each day

(pneumonic “Sige Caps”)

  • Mood*
  • Sleep
  • Interest*
  • Guilt or Hopelessness
  • Energy
  • Concentration
  • Appetite
  • Psychomotor
  • Suicidal/Homocidal Ideation

*Depressed Mood or Anhedonia must be present

nature vs nurture
Nature vs Nurture
  • MDD is strongly genetic, with well over 100 genes involved.
  • However, the largest risk for developing MDD as an adult is losing a parent before age 12.
  • Many Environmental, Psychological and Sociological factors can effect it.

10

medical disease can appear as major depressive disorder
Medical Disease can appear as Major Depressive Disorder
  • Many Medical Diseases can appear as MDD. R/O:
    • Hypothyroidism
    • Anemia, both Microcytic and Macrocytic
    • Any inflammatory Disease
    • Hyperparathyroidism (even slightly elevated Ca++ may be important)
    • Various Vitamin deficiencies, including: D, B12, B6, Folate, etc.
      • Vitamin D deficiency seems more common since the use of high SPF Sunscreens.

11

other free scales
Other (Free) Scales
  • PHQ 2 Screener
    • ( Very brief. I don’t encourage its’ use).
  • Zung Depression Rating Scale
  • QIDS-SR
    • Quick Inventory Depressive Symptomatology (Self Report)
  • CUDOS
    • Clinically Useful Depression Outcome Scale
treat to remission sub syndromal depression relapse
Treat to Remission!Sub-Syndromal Depression = Relapse

One or more Symptoms

7 months until Relapse!

No Symptoms

Months Well

Judd 1998

symptoms and circuits
Symptoms and Circuits
  • Advocated by
  • Stephen M. Stahl, MD
slide17
When a Brain Circuit, when overstimulated or under-stimulated, it will produce certain symptoms.(adapted from Steven Stahl, MD)
slide18
Each Symptom, regardless of the disease, comes from the Same Circuit Malfunction!(adapted from Steven Stahl, MD)
symptoms circuits
Symptoms & Circuits
  • By Knowing Which Symptom is related to which Circuit,
  • and by Knowing How Each Medication Effects Each Circuit
  • You can Logically Deduce Which Medication Will Best Treat Most Mental Conditions.
  • (adapted from Steven Stahl, MD)
slide21

Circuits

Serotonin

slide22

Circuits

Serotonin

Norepinephrine

slide23

Circuits

Serotonin

Norepinephrine

Dopamine

symptoms associated with serotonin
Symptoms associated with Serotonin
  • Serotonin helps us “Cope”.
  • If Serotonin is too Low: Irritable, Anxious, Easily Overwhelmed, Hopeless, Suicidal, “poor sense of Well-being”
  • If Serotonin is too High: Serotonin Syndrome; Agitation, Fasciulations, Hyperthermia, Vital Sign Disturbance, leading to stupor, come then death. [Although pharmacists warn of this, neither I nor any Psychiatric Colleagues have ever seen this condition. So it appears to be very rare.]
symptoms associated with norepinephrine
Symptoms associated with Norepinephrine
  • Norepinephrine is like “Adrenaline”.
  • If Norepinephrine too Low: Anergy, Immediate Memory Impaired, Psychomotor Retardation.
  • If Norepinephrine too High: Irritable, Agitation, Insomnia. (Similar Symptoms to Low Serotonin).
symptoms associated with dopamine
Symptoms associated with Dopamine
  • Dopamine provides Interests/Desire, mentally. (Dopamine has other physical functions as well).
  • If Dopamine too Low: Apathy, Dementia, Muscle
  • If Dopamine too High: Hedonism, Psychosis, Mania
slide28

Symptoms & Circuits

Serotonin

Mood*

Emotion

Cognitive Function

Norepinephrine

Dopamine

slide29

Symptoms & Circuits

Serotonin

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Mood*

Emotion

Cognitive Function

Norepinephrine

Dopamine

slide30

Symptoms & Circuits

Serotonin

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Norepinephrine

Dopamine

slide31

Symptoms & Circuits

Serotonin

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Norepinephrine

Dopamine

slide32

Symptoms & Circuits

Serotonin

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Norepinephrine

Dopamine

slide33

Symptoms & Circuits

Serotonin

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

slide34

Symptoms & Circuits

Serotonin

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Appetite

Aggression

Sex

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

Slaby and Tancradi 2002, Stahl 2004

slide36

5HT1a

5HT1a

classes of antidepressants
Classes of Antidepressants
  • SSRIs
  • SNRIs, NaSSI
  • SDRIs
  • NDRIs (mechanism of Wellbutrin not fully understood)
  • DRIs, DAgs
  • NRIs – (not very effective).
  • (MOAIs, not covered here, are powerful Antidepressants; but carry HTN risk with certain foods and/or meds and Serotonin Syndrome with SRIs.)
suicidality vs suicide
Suicidality vs Suicide
  • An ironic fact about Antidepressant use is that Suicidality risk (thoughts, not death) increases transiently, BUT SUICIDE (DEATH) risk DECREASES in patients less than 24 y.o.! (expound)
ssris
SSRIs
  • “Multi Action” – ssri, 5HT1a, 1b, 3, & 7.
      • Vortioxetine (Brintellix).
  • “Dual Action”- SSRI & 5HT1a.
      • Vilazadone (Viibryd).
  • “Single Action”– SSRI.
      • Escitalpram (Lexapro).
      • Fluoxetine (Prozac). SSRI + bits of others.
  • “Half Action” - Racemic mixture, half active.
      • Cilatopram (Celexa).
slide41

Symptoms, Circuits & Medications-Trade Names

Larry O. Sanders, MD

c 2002, 2014

“Multi Action”- Brintellix 5-20mg

“Dual Action” - Viibryd 10-40mg

“Single Action”- Lexapro 10-20mg

Prozac 20mg

“Half Action” - Celexa 40mg

SSRI

Serotonin

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Appetite

Aggression

Sex

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

snris
SNRIs
  • Levomilnacipram (Fetzima) 1:2 S:N
  • Duloxetine (Cymbalta) 9:1 S:N
  • Desvenlafaxine (Pristiq) 15:1 S:N
  • Venlafaxine(Effexor) 30:1 S:N
    • At low dose is SSRI. At high dose SNRI. Strong W/D issues!
  • {Paroxetine (Paxil) 20-40mg}
    • Weight gain, Fatigue, Strong W/D issues!
slide44

Symptoms, Circuits & Medications-Trade Names

Larry O. Sanders, MD

c 2002, 2014

“Multi Action”- Brintellix 5-20mg

“Dual Action” - Viibryd 10-40mg

“Single Action”- Lexapro 10-20mg

Prozac 20mg

“Half Action” - Celexa 40mg

SSRI

Fetzima 40-120mg

Cymbalta 60mg

Pristiq 50-100mg

Effexor 75-375mg

(Paxil) 20mg

Serotonin

SNRI

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Appetite

Aggression

Sex

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

nassa indirectly elevates norepinephrine noradrenaline and serotonin
NaSSAIndirectly elevates Norepinephrine (Noradrenaline) and Serotonin
  • Mirtazapine (Remeron)
      • Sedating, increases appetite and weight gain.
slide46

Symptoms, Circuits & Medications-Trade Names

Larry O. Sanders, MD

c 2002, 2014

“Multi Action”- Brintellix 5-20mg

“Dual Action” - Viibryd 10-40mg

“Single Action”- Lexapro 10-20mg

Prozac 20mg

“Half Action” - Celexa 40mg

SSRI

Fetzima 40-120mg

Cymbalta 60mg

Pristiq 50-100mg

Effexor 75-375mg

(Paxil) 20mg

Serotonin

SNRI

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Remeron 30-45mg

(Indirect ^ S & N)

Appetite

Aggression

Sex

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

slide48
NDRI
  • Bupropion (Wellbutrin) 300-450mg
    • IR. Not Well Tolerated.
    • SR. Lasts 12 hours.
    • XL. Lasts 24 hours.
amphetamines
Amphetamines
  • Terminal Releasers

and

  • Reuptake Inhibitors

of Norepinephrine and Dopamine

slide50

Symptoms, Circuits & Medications-Trade Names

Larry O. Sanders, MD

c 2002, 2014

“Multi Action”- Brintellix 5-20mg

“Dual Action” - Viibryd 10-40mg

“Single Action”- Lexapro 10-20mg

Prozac 20mg

“Half Action” - Celexa 40mg

SSRI

Fetzima 40-120mg

Cymbalta 60mg

Pristiq 50-100mg

Effexor 75-375mg

(Paxil) 20mg

Serotonin

SNRI

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Remeron 30-45mg

(Indirect ^ S & N)

Appetite

Aggression

Sex

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

NDRI

NRI

Wellbutrin 300-450mg

Amphetamines 10-30mg b.i.d.

sdris
SDRIs
  • Sertraline (Zoloft)
    • Usual Dose range 50-200 mg/d
    • One of the best tolerated, most effective AD.
slide53

Symptoms, Circuits & Medications-Trade Names

Larry O. Sanders, MD

c 2002, 2014

“Multi Action”- Brintellix 5-20mg

“Dual Action” - Viibryd 10-40mg

“Single Action”- Lexapro 10-20mg

Prozac 20mg

“Half Action” - Celexa 40mg

SSRI

Fetzima 40-120mg

Cymbalta 60mg

Pristiq 50-100mg

Effexor 75-375mg

(Paxil) 20mg

Serotonin

SNRI

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Zoloft

50-200mg

SDRI

Remeron 30-45mg

(Indirect ^ S & N)

Appetite

Aggression

Sex

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

NDRI

NRI

Wellbutrin 300-450mg

Amphetamines 10-30mg b.i.d.

dri dags
DRI & DAgs
  • Methylphenidate (Ritalin)
  • Dopamine Agonists:
    • Pramipexole (Mirapex).
      • Evidence based treatment. Avg dose 0.95 mg.
    • Ropinirole (Requip).
slide56

Symptoms, Circuits & Medications-Trade Names

Larry O. Sanders, MD

c 2002, 2014

“Multi Action”- Brintellix 5-20mg

“Dual Action” - Viibryd 10-40mg

“Single Action”- Lexapro 10-20mg

Prozac 20mg

“Half Action” - Celexa 40mg

SSRI

Fetzima 40-120mg

Cymbalta 60mg

Pristiq 50-100mg

Effexor 75-375mg

(Paxil) 20mg

Serotonin

SNRI

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Zoloft

50-200mg

SDRI

Remeron 30-45mg

(Indirect ^ S & N)

Appetite

Aggression

Sex

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

NDRI

NRI

DRI

Ritalin 10-40mg bid

Mirapex 0.25-1.5 mg HS

Wellbutrin 300-450mg

Amphetamines 10-30mg b.i.d.

DAg

slide58
NRIs
  • Desiparamine
  • Atomoxetine (Strattera)
    • (Atomoxetine is a failed antidepressant approved for use in AD/HD. No NRI, other than the TCA Desipramine, has beat placebo).
slide59

Symptoms, Circuits & Medications-Trade Names

Larry O. Sanders, MD

c 2002, 2014

“Multi Action”- Brintellix 5-20mg

“Dual Action” - Viibryd 10-40mg

“Single Action”- Lexapro 10-20mg

Prozac 20mg

“Half Action” - Celexa 40mg

SSRI

Fetzima 40-120mg

Cymbalta 60mg

Pristiq 50-100mg

Effexor 75-375mg

(Paxil) 20mg

Serotonin

SNRI

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Zoloft

50-200mg

SDRI

Remeron 30-45mg

(Indirect ^ S & N)

Appetite

Aggression

Sex

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

NDRI

NRI

DRI

Desipramine

Strattera

Ritalin 10-40mg bid

Mirapex 0.25-1.5 mg HS

Wellbutrin 300-450mg

Amphetamines 10-30mg b.i.d.

DAg

slide60

Symptoms, Circuits & Medications-Trade Names

Larry O. Sanders, MD

c 2002, 2014

“Multi Action”- Brintellix 5-20mg

“Dual Action” - Viibryd 10-40mg

“Single Action”- Lexapro 10-20mg

Prozac 20mg

“Half Action” - Celexa 40mg

SSRI

Fetzima 40-120mg

Cymbalta 60mg

Pristiq 50-100mg

Effexor 75-375mg

(Paxil) 20mg

Serotonin

SNRI

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Zoloft

50-200mg

SDRI

Remeron 30-45mg

(Indirect ^ S & N)

Appetite

Aggression

Sex

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

NDRI

NRI

DRI

Desipramine

Strattera

Ritalin 10-40mg bid

Mirapex 0.25-1.5 mg HS

Wellbutrin 300-450mg

Amphetamines 10-30mg b.i.d.

DAg

slide61

Symptoms, Circuits & Medications-Trade Names

Larry O. Sanders, MD

c 2002, 2014

“Multi Action”- Brintellix 5-20mg

“Dual Action” - Viibryd 10-40mg

“Single Action”- Lexapro 10-20mg

Prozac 20mg

“Half Action” - Celexa 40mg

SSRI

Fetzima 40-120mg

Cymbalta 60mg

Pristiq 50-100mg

Effexor 75-375mg

(Paxil) 20mg

Serotonin

SNRI

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Zoloft

50-200mg

SDRI

Remeron 30-45mg

(Indirect ^ S & N)

Appetite

Aggression

Sex

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

NDRI

NRI

DRI

Desipramine

Strattera

Ritalin 10-40mg bid

Mirapex 0.25-1.5 mg HS

Wellbutrin 300-450mg

Amphetamines 10-30mg b.i.d.

DAg

slide62

Symptoms, Circuits & Medications-Trade Names

Larry O. Sanders, MD

c 2002, 2014

“Multi Action”- Brintellix 5-20mg

“Dual Action” - Viibryd 10-40mg

“Single Action”- Lexapro 10-20mg

Prozac 20mg

“Half Action” - Celexa 40mg

SSRI

Fetzima 40-120mg

Cymbalta 60mg

Pristiq 50-100mg

Effexor 75-375mg

(Paxil) 20mg

Serotonin

SNRI

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Zoloft

50-200mg

SDRI

Remeron 30-45mg

(Indirect ^ S & N)

Appetite

Aggression

Sex

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

NDRI

NRI

DRI

Desipramine

Strattera

Ritalin 10-40mg bid

Mirapex 0.25-1.5 mg HS

Wellbutrin 300-450mg

Amphetamines 10-30mg b.i.d.

DAg

slide63

Symptoms, Circuits & Medications-Trade Names

Larry O. Sanders, MD

c 2002, 2014

“Multi Action”- Brintellix 5-20mg

“Dual Action” - Viibryd 10-40mg

“Single Action”- Lexapro 10-20mg

Prozac 20mg

“Half Action” - Celexa 40mg

SSRI

Fetzima 40-120mg

Cymbalta 60mg

Pristiq 50-100mg

Effexor 75-375mg

(Paxil) 20mg

Serotonin

SNRI

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Zoloft

50-200mg

SDRI

Remeron 30-45mg

(Indirect ^ S & N)

Appetite

Aggression

Sex

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

NDRI

NRI

DRI

Desipramine

Strattera

Ritalin 10-40mg bid

Mirapex 0.25-1.5 mg HS

Wellbutrin 300-450mg

Amphetamines 10-30mg b.i.d.

DAg

slide64

Symptoms, Circuits & Medications-Trade Names

Larry O. Sanders, MD

c 2002, 2014

“Multi Action”- Brintellix 5-20mg

“Dual Action” - Viibryd 10-40mg

“Single Action”- Lexapro 10-20mg

Prozac 20mg

“Half Action” - Celexa 40mg

SSRI

Fetzima 40-120mg

Cymbalta 60mg

Pristiq 50-100mg

Effexor 75-375mg

(Paxil) 20mg

Serotonin

SNRI

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Zoloft

50-200mg

SDRI

Remeron 30-45mg

(Indirect ^ S & N)

Appetite

Aggression

Sex

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

NDRI

NRI

DRI

Desipramine

Strattera

Ritalin 10-40mg bid

Mirapex 0.25-1.5 mg HS

Wellbutrin 300-450mg

Amphetamines 10-30mg b.i.d.

DAg

slide65

Symptoms, Circuits & Medications-Trade Names

Larry O. Sanders, MD

c 2002, 2014

“Multi Action”- Brintellix 5-20mg

“Dual Action” - Viibryd 10-40mg

“Single Action”- Lexapro 10-20mg

Prozac 20mg

“Half Action” - Celexa 40mg

SSRI

Fetzima 40-120mg

Cymbalta 60mg

Pristiq 50-100mg

Effexor 75-375mg

(Paxil) 20mg

Serotonin

SNRI

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Zoloft

50-200mg

SDRI

Remeron 30-45mg

(Indirect ^ S & N)

Appetite

Aggression

Sex

Irritability

Anxiety

Mood*

Emotion

Cognitive Function

Energy

Alertness

Psychomotor

Working Memory

Desire

Interest*

Concentration

Motivation

Norepinephrine

Dopamine

NDRI

NRI

DRI

Desipramine

Strattera

Ritalin 10-40mg bid

Mirapex 0.25-1.5 mg HS

Wellbutrin 300-450mg

Amphetamines 10-30mg b.i.d.

DAg

compliance no involvement no commitment
Compliance“No Involvement, No Commitment”
  • Month 1 40% of Patients are off meds.
  • Month 2 60% of Patients are off meds.
    • S/E-Weight Gain, Sexual Dysfunction, Emotional Blunting, Cognitive Dysfunction.
    • Don’t Realize the Condition is Genetic.
    • Confusion with Treatment vs Cure.
when 1 st line fails in mdd
When 1st Line Fails in MDD
  • Refer to Venn Diagram to
    • Increase Dose,
    • Change Meds or
    • Augment.
  • 5HT1a - Abilify, Seroquel, Viibryd.
  • Lithium.
don t underdose
Don’t Underdose!

If dose 50-200, PCP often give 50mg, maybe 75 mg.

“You haven’t reached maximum dose until you have reached effect or intolerable side effects.”

the most common causes of treatment failure
The Most Common Causes of Treatment Failure
  • Non-Compliance.
  • Comorbid Anxiety.
  • Bipolar Depression.
    • Most experts believe that 20-30% of all Depressed Patients have a Bipolar Disorder
  • Comorid Substance Abuse
  • Depression with Psychosis (47% risk of manifesting BP1 or BP11 with in 10 years).
when is more than mdd involved
When is more than MDD Involved?
  • Anxiety
  • Psychosis
  • Mania
  • Substance Abuse
anxiety
Anxiety
  • Anxiety Disorders are present in 20% PC Pts.
  • Depression and Anxiety are HIGHLY Co-Morbid.
  • If Depression present, 60% Chance of having Significant Anxiety Disorder AND vice versa.
  • Untreated Anxiety consumes
    • 6x more of your time &
    • 6x more resources.
  • Most Antidepressants Treat Anxiety Disorders, but it is Really Important to Know How to Select Proper Medication.
types of anxiety disorders
Types of Anxiety Disorders
  • Generalized Anxiety Disorder (GAD) - Chronic Worry.
  • Social Phobia (aka Social Anxiety) - Fear Social Judgement.
  • Panic Disorder- Sudden, Intense Fear with Physical Symptoms.
  • Post-traumatic Stress Disorder (PTSD) - symptoms delayed by > 1 month after trauma. Can be years. For every 1 soldier killed in action in Afganistan, 25 will die by suicide.
  • Acute Stress Disorder - within 1 month of trauma.
  • Obsessive-Compulsive Disorder (OCD) - Germs, Order, Counting, that they have Harmed to Others.
anxiety rating scales
Anxiety Rating Scales
  • GAD 7 - Rates GAD
  • Zung Anxiety
  • CUXOS
  • YBOCS - for OCD
treatment of anxiety disorders
Treatment of Anxiety Disorders
  • Antidepressants
    • Serotonin Agents treat all.
    • NE helps GAD, but may make Panic Worse.
  • BZs
  • Gabapentin
be certain it s not bipolar depression
Be Certain It’s NOT Bipolar Depression!
  • Experts agree that 30-40% of
  • ALL Depressive Disorders
  • have a component of
  • Bipolar Disorder
slide78

Bipolar Mood States

Bipolar I

Bipolar II

(146 pts, 12.8 yrs)

(86 pts, 13.4 yrs)

1%

2%

% of Weeks

6%

9%

46%

53%

50%

46%

32%

50%

46%

46%

Adapted from Judd 2002

Judd 2003

treating bipolar disorder
Treating Bipolar Disorder
  • Treating Bipolar Disorder is often a Complex Challenge, much more difficult than treating Depression or Anxiety.
  • “Every Bipolar is an “n of 1.”
  • Must treat Current State and
  • Prevent both Mania and Depression.
if psychotic depression
If Psychotic Depression
  • Treat BOTH Psychosis and Mood.
  • Psychotic Depression is a High Risk for having an underlying Bipolar Disorder
non medical treatments
Non-Medical Treatments
  • Individual Psychotherapies
      • CBT, Supportive, Psychodynamic.
      • Exercise
  • Family Therapy
  • Group Therapy
when to refer
When to Refer
  • Anytime you are uncomfortable.
  • When Gravely Disabled, Imminently Suicidal or Homocidal (SEND TO ER!!!)
  • Mania is present
  • Psychosis present
  • Anxiety doesn’t respond rapidly (Suicide Risk)
  • When Substance Abuse present
  • Therapy Needed or Helpful.
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