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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

Next comes Sleep Hygiene

And Exercise

And Behavioral Activation

Antidepressants are no better than placebo for mild to moderate depression

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

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)

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

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

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

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

Monitor with PHQ-9 or WHO-DAS

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