Treating Depressionin the Primary Care SettingPharmacologic InterventionsPresented by: Jonathan Betlinski, MDDate: 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 uphttp://www.nimh.nih.gov/health/publications/depression/index.shtml#pub6

Next comes Sleep Hygienewww.cci.health.wa.gov.au/docs/Info-sleep%20hygiene.pdf

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

And Behavioral Activationwww.personal.kent.edu/~dfresco/CBT_Readings/BM_Lejuez_BATD_Manual.pdf

Antidepressants are no better than placebo for mild to moderate depressionhttp://medicine.plosjournals.org/archive/1549-1676/5/2/pdf/10.1371_journal.pmed.0050045-L.pdf

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

• 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

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

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

Pharmacology – Nonresponse

• Reappraise diagnosis• Assess side effects• Assess comorbid conditions• Review psychosocial factors• Check treatment adherence• Check on psychotherapy progress• Consider medication switch vs. augmenthttp://psychiatryonline.org/pdfaccess.ashx?ResourceID=243261&PDFSource=6

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

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

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

Monitor with PHQ-9 or WHO-DAShttp://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