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Treating Depression in the Primary Care Setting . Pharmacologic Interventions. Presented by: Jonathan Betlinski, MD. Date: 09/25/2014. Disclosures and Learning Objectives. Learning Objectives Describe the Acute, Continuation and Maintenance phases of MDD treatment

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Treating Depressionin the Primary Care Setting

Pharmacologic Interventions

Presented by: Jonathan Betlinski, MD

Date: 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 up

http://www.nimh.nih.gov/health/publications/depression/index.shtml#pub6

Next comes Sleep Hygiene

www.cci.health.wa.gov.au/docs/Info-sleep%20hygiene.pdf

And Exercise

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3674785/pdf/nihms-386053.pdf

And Behavioral Activation

www.personal.kent.edu/~dfresco/CBT_Readings/BM_Lejuez_BATD_Manual.pdf

Antidepressants are no better than placebo for mild to moderate depression

http://medicine.plosjournals.org/archive/1549-1676/5/2/pdf/10.1371_journal.pmed.0050045-L.pdf


Pharmacology acute phase
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
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
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 line

http://psychiatryonline.org/pdfaccess.ashx?ResourceID=243261&PDFSource=6

https://www.icsi.org/_asset/fnhdm3/Depr-Interactive0512b.pdf


Pharmacology nonresponse
Pharmacology – Nonresponse

Reappraise diagnosis

Assess side effects

Assess comorbid conditions

Review psychosocial factors

Check treatment adherence

Check on psychotherapy progress

Consider medication switch vs. augment

http://psychiatryonline.org/pdfaccess.ashx?ResourceID=243261&PDFSource=6

https://www.icsi.org/_asset/fnhdm3/Depr-Interactive0512b.pdf


Pharmacology nonresponse changing
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 antipsychotic

http://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 depression

http://psychiatryonline.org/pdfaccess.ashx?ResourceID=243261&PDFSource=6

Monitor with PHQ-9 or WHO-DAS

http://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


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