initiation of antidepressants in primary caresnapaprn.org/pdfs/initiation of antidepressants in...

Avoiding

Potentially

Dangerous

Treatment

Delays

INITIATION OF

ANTIDEPRESSANTS IN

PRIMARY CARE

Define Depressive Disorders

Identify Useful Screening Tools

Identify When to Initiate Antidepressants

Distinguish Between Types of Antidepressants

to Predict & Evaluate Efficacy

OBJECTIVES

Strive to be a healer, not a

technician.

Allan Peterkin, MD

DSM IV-TR (2000)

Major Depressive Disorder

Single Episode (296.2x)

Recurrent (296.3x)

Mild, Moderate, Severe without & with psychotic

features, Partial & Full Remission

Coded 296.x1-6

DEPRESSIVE DISORDERS

5 or more symptoms present in same 2 -week period, a change

in previous functioning, at least 1 is depressed mood or loss

of interest/pleasure

Not mixed with manic symptoms

Cause clinically significant distress/impaired functioning

Not due to substances, general medical condition, grief

Marked preoccupation with worthlessness, suicidal ideation,

psychotic symptoms, psychomotor retardation

MAJOR DEPRESSIVE DISORDER

Depressed mood most days: sad, empty, irritable

Marked loss of interest or pleasure

Weight loss when not dieting, e.g. >5% in a month

Insomnia or Hypersomnia

Psychomotor retardation or agitation, observable by others

Fatigue or loss of energy

Feelings of worthlessness or guilt

Difficulty concentrating, or indecisiveness

Recurrent thoughts of death, suicidal ideation

With or without plan

WE MUST ASK

SPECIFIC DEPRESSIVE SYMPTOMS

DSM IV-TR

Dysthymic Disorder (300.4)

Chronic, less severe depressive symptoms

Present for many years


DSM IV-TR

Substance-Induced Mood Disorder (292.84)

Mood Disorder NOS (296.90)

Mood Disorder Due to General Medical Condition

(293.83)

INCREASES RISK OF SUICIDE


Rates vary depending on specific condition

Chronic, incurable, painful conditions carry

the greatest risk

WE MUST ASK

SUICIDE

& GENERAL MEDICAL CONDITIONS

DSM 5 (2013 – due out in May)

Disruptive Mood Dysregulation Disorder (previously described as Pediatric Bipolar D/O

Premenstrual Dysphoric Disorder

>5 of 12 months, 1 week before menses

Mixed Anxiety/Depression

At least 3 symptoms of MDD or GAD

Major correlate to suicidal thoughts


Dystonic: Patient is aware & in pain

Severe impairment in functioning

Correlation to drug use, especially EtOH,

amphetamines, cocaine

Powerful correlate to suicide

DSM 5 DEPRESSIVE DISORDERS

Wide Variety

Clinician vs Client/Self Rating

Time Involved: 2-30 minutes

Public Domain vs Copyrighted

Realistic Application: Valid & Brief

SCREENING TOOLS

Choosing a Rating Scale

Consider your Population

Scale Validity & Reliability

Assessing what it’s designed to assess

Ability to provide consistent, reproducible info

Available Staff Resources, Time, Training

Scale Standardization

Ease of Participation by Patient

SCREENING TOOLS

Hamilton Rating Scale for Depression (HAM-D, 1960)

17-31 items, public, 30 minutes

Beck Depression Inventory (BDI, 1961; BDI -II , 1993)

21 items, copyright, 5-10 minutes

Montgomery -Asberg Depression Rating Scale (MADRS, 1979)

10 items, public, 20 minutes

Raskin-Covi Scales (1969, 1981)

6 items, public, several minutes

Mood Disorder Questionnaire (MDQ, 2000)

13 items, public, 5-10 minutes, screens for Bipolar Disorder

SCREENING TOOLS

Examples Included

Raskin-Covi Scales

Observer Rated

Severity score used in pharmacologic study

outcome

MADRS

Observer Rated

Does not cover somatic or psychomotor symptoms

as fully as HAM-D

SCREENING TOOLS

Make even your first

assessment a therapeutic

experience for the patient. One

encounter may actually be

enough or all the patient can

afford right now.

Allan Peterkin, MD

WHEN MIGHT IT BE NECESSARY TO

INITIATE ANTIDEPRESSANTS

You may be the First & Only Provider

(Un)Availability or (Un)Desirability of

Psychiatric Providers

Severity of symptoms vs Time delay

?

Important Considerations

Patient has significant distress/impaired function

Patient has no capacity to cope with problem

Patient is motivated for treatment

Patient has thoughts or intentions of suicide

Consider in-patient referral


INITIATE ANTIDEPRESSANTS?

Additional Important Considerations

Less risk than long-term Benzodiazepine use

Discuss Black Box Warnings

Discuss risk of mania if Bipolar D/O is possible

Serotonin Syndrome potential

Consider non-psychiatric drugs patient takes


INITIATE ANTIDEPRESSANTS?

Why are there so many different

antidepressant drugs?

Why is the efficacy so unpredictable?

Consider: There are 3 known Serotonin

receptor genes

TYPES OF ANTIDEPRESSANT DRUGS-

PREDICTING & EVALUATING EFFICACY

Monoamine Oxidase Inhibitors

Example: Parnate (Tranylcypromine)

Indications: Refractory Depression

Dosing: 30 mg/day, divided; max 60 mg/day

Concerns: Numerous

Hypertensive Crisis w/ sympathomimetics, levo-dopa, high-tyramine foods e.g. cheese, chocolate, yogurt, wine, beer

Must stop other drugs 1-5 weeks before use

Less problematic with transdermal EMSAM

TYPES OF ANTIDEPRESSANT DRUGS –


Tricyclics

Example: Elavil (Amitriptyline)

Indications: Depression, especially endogenous; also used in pain management

Dosing: 10-75 mg/day; max 150 mg/day

Concerns: Numerous

Hyperpyretic crisis w/ MAOIs, anticholinergics, sympathomimetics

Paralytic ileus w/ anticholinergics

Arrhythmias

Galactorrhea



Tricyclics

Example: Tofranil (Imipramine)

Indications: Depression; off-label nocturnal enuresis


Concerns: Numerous

Urinary retention

Hyperpyretic crisis, convulsions, death w/ MAOIs

Arrhythmias

EPS



Serotonin Specific Reuptake Inhibitors

Example: Prozac (Fluoxetine)

Indications: MDD, Bulimia nervosa, Panic D/O, OCD


Concerns: Suicidal Ideation Warning

Long half-life

Increased risk of bleeding with drugs that affect coagulation (menorrhagia even w/o these)

Serotonin Syndrome (weakness, incoordination, hyper-reflexia, tachycardia, confusion, agitation)

Sexual side effects



SSRIs

Example: Paxil (Paroxetine)

Indications: Depression, PMDD, Social Anx D/O, Panic D/O



Highly protein bound

Serotonin syndrome

Abnormal bleeding

Sexual side effects



SSRIs

Example: Zoloft (Sertraline)

Indications: Depression, PMDD, Panic D/O, PTSD,

OCD, Social Anxiety D/O



Serotonin Syndrome

Diaphoresis

Sexual side effects



SSRIs

Example: Lexapro (Escitalopram)

Indications: MDD, GAD



Serotonin Syndrome

Abnormal bleeding

Interacts with Tramadol

Sexual side effects



SSRI + 5-HT1A Receptor Partial Agonist

Viibryd (Vilazodone)

Indications: MDD




Abnormal bleeding

Serotonin Syndrome with concomitant drugs, but less likely as partial agonist takes place of 5-HT that’s been inhibited



Serotonin-Norepinephrine Reuptake Inhibitors

Example: Effexor (Venlafaxine)

Indications: MDD, GAD, Social AnxD/O, Panic D/O

Dosing: 37.5-225 mg/day; max 375 mg/day


Hypertension

Serotonin Syndrome

Abnormal bleeding

Severe discontinuation sx, e.g. paresthesia, tremor, GI, agitation (titrate extremely slowly)



SNRIs

Example: Pristiq (Desvenlafaxine)

Indications: MDD; in trials for “Hot Flashes”



Possible Hypertension

Serotonin Syndrome

Hyperhidrosis, mydriasis

Can give 50mg qod in ESRD



SNRIs

Example: Cymbalta (Duloxetine)

Indications: MDD, GAD




Possible Hypertension

Hepatotoxicity, avoid w/ excessive EtOH use



Other Classes

Example: Wellbutrin (Bupropion)

Indications: Depression, Seasonal Affective D/O



Increased seizure risk, especially >300mg/day

If seizure occurs, D/C & do not restart

If b.i.d. dosing, give 8 hrs apart & last dose by 5pm

Possible Hypertension w/ nicotine replacement



Other Classes

Example: Remeron (Mirtazapine)

Indications: MDD, off-label appetite & sleep aid

Dosing: 7.5-45 mg/day; max 45 mg/day


Serotonin Syndrome

Possible fatal reactions with MAOIs

Dose at HS

7.5 mg dose-most SE increasing appetite & sleep



Other Classes

Example: Desyrel (Trazodone)

Indications: Depression

Dosing: 25-300 mg/day; max 600 mg/day (inpt)

Concerns: May affect anticoagulants

Drowsiness, dizziness, hypotension

Headache

Potentiates EtOH, other CNS depressants

Most often used in lower doses for sleep aid



Antiepileptics

Examples: Depakote, Lamictal, Trileptal, Topamax

Antipsychotics

Examples: Abilify, Geodon, Risperdal, Seroquel, Zyprexa, Symbyax (Olanzapine/Fluoxetine)

Lithium

Used as Mood Stabilizers

May be essential to effectively treat Bipolar D/O

ADJUNCT THERAPY

You are seldom helping

only the patient in front of

you.

You are helping their

partners, children,

employees, and friends.

Allan Peterkin, MD

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

disorders (4 th ed.), Text Revision. Washington, DC: APA.

Ernst, D. (Ed.). (2012). Mood disorders, Anxiety/OCD. Nurse Practitioners’ Prescribing

Reference, 19 (4).

Klott, J. (2012). Revolutionizing diagnosis & treatment using the DSM -5. Eau Claire, WI: CMI

Education Institute.

Mullen, J. (Ed.). (2004). Manual of rating scales for the assessment of mood disorders.

Wilmington, DE: AstraZeneca Pharmaceuticals, LP.

Peterkin, A. (1999). The psychiatrist’s little book of wisdom: 350 tips and reflections on

clinical practice and the art of communicating. Royal Oak, MI: Physicians’ Press.

REFERENCES

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