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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.


In us major depression is a common medical illness
In US, Major Depression is aCommon Medical Illness


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


Getting the most of antidepressants rvu 05 03 2014

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 Risk@ 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



Getting the most of antidepressants rvu 05 03 2014
When a Brain Circuit, when overstimulated or under-stimulated, it will produce certain symptoms.(adapted from Steven Stahl, MD)


Getting the most of antidepressants rvu 05 03 2014
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)



Getting the most of antidepressants rvu 05 03 2014

Circuits

Serotonin


Getting the most of antidepressants rvu 05 03 2014

Circuits

Serotonin

Norepinephrine


Getting the most of antidepressants rvu 05 03 2014

Circuits

Serotonin

Norepinephrine

Dopamine


Symptoms associated with these circuits
SymptomsAssociated with theseCircuits


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


Getting the most of antidepressants rvu 05 03 2014

Symptoms & Circuits

Serotonin

Mood*

Emotion

Cognitive Function

Norepinephrine

Dopamine


Getting the most of antidepressants rvu 05 03 2014

Symptoms & Circuits

Serotonin

Suicidal/Homicidal

Frustration, “Sense of Well Being”

Obsession, Sleep, Guilt or Hopelessness

Mood*

Emotion

Cognitive Function

Norepinephrine

Dopamine


Getting the most of antidepressants rvu 05 03 2014

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


Getting the most of antidepressants rvu 05 03 2014

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


Getting the most of antidepressants rvu 05 03 2014

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


Getting the most of antidepressants rvu 05 03 2014

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


Getting the most of antidepressants rvu 05 03 2014

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



Getting the most of antidepressants rvu 05 03 2014

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).


  • Getting the most of antidepressants rvu 05 03 2014

    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


    Medications effecting both serotonin and norepinephrine
    Medications effecting Both Serotonin and Norepinephrine


    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!


    Getting the most of antidepressants rvu 05 03 2014

    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.


    Getting the most of antidepressants rvu 05 03 2014

    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


    Medications effecting norepinephrine and dopamine
    Medications Effecting Norepinephrineand Dopamine


    Getting the most of antidepressants rvu 05 03 2014
    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


    Getting the most of antidepressants rvu 05 03 2014

    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.


    Medication effecting serotonin and dopamine
    Medication Effecting Serotoninand Dopamine


    Sdris
    SDRIs

    • Sertraline (Zoloft)

      • Usual Dose range 50-200 mg/d

      • One of the best tolerated, most effective AD.


    Getting the most of antidepressants rvu 05 03 2014

    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).


    Getting the most of antidepressants rvu 05 03 2014

    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



    Getting the most of antidepressants rvu 05 03 2014
    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).


    Getting the most of antidepressants rvu 05 03 2014

    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


    Getting the most of antidepressants rvu 05 03 2014

    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


    Getting the most of antidepressants rvu 05 03 2014

    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


    Getting the most of antidepressants rvu 05 03 2014

    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


    Getting the most of antidepressants rvu 05 03 2014

    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


    Getting the most of antidepressants rvu 05 03 2014

    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


    Getting the most of antidepressants rvu 05 03 2014

    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.”


    Just when i learned all of life s answers they changed the questions
    Just When I Learned All of Life’s Answers,They Changed the Questions!


    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


    Getting the most of antidepressants rvu 05 03 2014

    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


    Mdq scoring
    MDQScoring



    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.


    Epitaph of the hypochondriac or the psych patient
    Epitaph of the Hypochondriac(or the Psych Patient)