Treating Depression
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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 Depression in the Primary Care Setting

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Treating depression in the primary care setting

Treating Depressionin the Primary Care Setting

Pharmacologic Interventions

Presented by: Jonathan Betlinski, MD

Date: 09/25/2014


Treating depression in the primary care setting

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.


Treating depression in the primary care setting

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


Treating depression in the primary care setting

SIG E CAPS for Depression

Ssleep decreased (or increased)

Iinterest decreased

Gguilt or worthlessness

Eenergy decreased

Cconcentration difficulties

Aappetite disturbance or weight loss

Ppsychomotor agitation or retardation

Ssuicidal thoughts

and depressed mood!


Treating depression in the primary care setting

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


Treating depression in the primary care setting

Pharmacology – Continuation Phase

Continue Acute Phase treatment

For 4-9 months

Monitor regularly for recurrence

Use depression-focused psychotherapy to help prevent relapse (CBT)


Treating depression in the primary care setting

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 the primary care setting

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


Treating depression in the primary care setting

The End!

Next Week's

Topic:

Assessing

Suicide

Risk


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