1. In a patient with a diagnosis of depression:
a) Assess the patient for the risk of suicide.
b) Decide on appropriate management (i.e., hospitalization or close follow-up, which will depend, for example, on severity of symptoms, psychotic features, and suicide risk).
Assessment
- Suicidality
- Bipolarity
- Comorbidity & concomitant medications
- Special features (psychosis, atypical features, seasonality)
- B/W if clinically indicated: LFT, metabolic workup
2 Screen for depression and diagnose it in high-risk groups (e.g., certain socio-economic groups, those who suffer from substance abuse, postpartum women, people with chronic pain).
7 In patients presenting with depression, inquire about abuse: – sexual, physical, and emotional abuse (past and current, witnessed or inflicted). – substance abuse.
Risk Factors
- Female, age 25-45
- Family Hx of depression / mood disorder
- Negative childhood experience
- Physical or mental Abuse
- Substance abuse
- Stressors
- Poor social support
- Dementia, post stroke/MI, postpartum <6mo
- HIV
- Chronic pain or chronic dz / chronic insomnia / fatigue
- Multiple unexplained somatic complaints
Screen with patient health questionnaire (2 Qs)
- During the past month, have you often been bothered by
- Feeling down, depressed or helpless?
- Little interest or pleasure doing things?
3 In a patient presenting with multiple somatic complaints for which no organic cause is found after appropriate investigations, consider the diagnosis of depression and explore this possibility with the patient.
Dx (Hx): > 2 wk of depressed mood or anhedonia most of the day, nearly every day + >= 5 of SIGECAPS
- Sleep
- Interest
- Guilt / hopelessness
- Energy
- Concentration
- Appetite
- Psychomotor retardation
- Suicidal ideation
R/o mania episodes, psychosis, anxiety symptoms or substance abuse
8 In a patient with depression, differentiate major depression from adjustment disorder, dysthymia, and a grief reaction.
Dysthymia:
- Chronically depressed mood for 2 yrs with 2 SIGECAPS
- no MDE is present in this period
Adjustment Disoer
- Stressor < 3mo and resolves in < 6mo
Grief reaction
- Loss, resolves <3mo
10 In the very young and elderly presenting with changes in behaviour, consider the diagnosis of depression (as they may not present with classic features).
Atypical:
- Reactive mood, over sleeping, over eating, leaden paralysis, interpersonal rejection, sensitivity
Children:
- More cognitive and fewer vegetative symptoms
- Irritable vs depressed mood
- S/Sx: insomnia, boredom, low self-esteem, deteriorating school performance, social withdrawal
- SNRI is the third line Tx – increase SI
Elderly
- Somatic c/o: wt change, sleep and energy issues, anxiety symptoms
- increased suicide risk
- screen with GDS
4 After a diagnosis of depression is made, look for and diagnose other co-morbid psychiatric conditions (e.g., anxiety, bipolar disorder, personality disorder).
9 Following failure of an appropriate treatment in a patient with depression, consider other diagnoses (e.g., bipolar disorder, schizoaffective disorder, organic disease).
- See Anxiety and personality disorder posts
Bipolar: DIGFAST
- Distractibility
- Imulsivity
- Grandiosity
- Flight of ideas
- Activities
- Sleep, decrease need
- Talkative
Bipolar I – >=1 manic episode – Tx with Lithium or valproic acid
- screen for pregnancy, order TSH, lipids, BUN, Cr, ECG before Lithium Rx (causes Diabetes insipidus and hypothyroidism)
Bipolar 2 >= 1 hypomanic episode + 1 MDE – Tx with antipsychotics
6 In a patient presenting with symptoms consistent with depression, consider and rule out serious organic pathology, using a targeted history, physical examination, and investigations (especially in elderly or difficult patients).
Organic causes
- Substance abuse
- DM, Thyroid, Pituitary, Vit B12, anemia, Calcium
- Dementia, Parkin’s, MS
- CVA, hepatitis
- OCPs, BZDs, betablockers, EtOH
Ix:
- CBC (r/o anemia), Lytes, Creatinine, TSH, folate, B12, LFTs
- ECG (prolonged QT is a contraindication for meds)
- Urine drug screen
5 In a patient diagnosed with depression, treat appropriately: – drugs, psychotherapy. – monitor response to therapy. – active modification (e.g., augmentation, dose changes, drug changes). – referral as necessary.
Best outcome resulted from antidepressants + CBT
- Monitor adherence & educate self-management techniques
- Carefully monitored Q1-2 wk at the onset of pharmacotherapy, f/u Q2-4 wk or longer
- Monitor with validated outcome scales – PHQ-9
Antidepressant
- individualized based on symptom profile, comorbidity, tolerability, previous response, potential interactions, pt preference, cost
1st line: CBT & IPT
- SSRI
- Fluoxetine (Prozac 20-80mg) & SSRIs – 1st line in pregnancy
- (except paroxetine – cardiac malformations)
- Citalopram (Celexa 20-60mg), nortriptyline, sertraline, paroxetine – 1st line in nursing mother
- Fluoxetine & Citalopram – 1st line in children
- (2nd line: Paroxetine ↑ S/E & 3rd line: Venlafaxine – ↑suicidality)
- Fluoxetine (Prozac 20-80mg) & SSRIs – 1st line in pregnancy
- SNRI (Venlafaxine – effexor 75-275mg & Duloxetine – cymbalta 60-120mg)
- NDRI (Bupropion – wellbutrin 150-300mg)
- α2 adrenergic agonist & 5-HT2 antagonist (Mirtazapine – remeron 30-60mg)
2nd line:
- TCAs (Amitriptyline), MAOi (Selegiline – emsam),
- SRI/5-HT2 antagonist (trazodone),
- Atypical antipsychotic (quetiapine XR)
- MDD + psychotic features, Tx w/ antidepressants + antipsychotic
Pt factors:
- Age & sex & comorbid disorders
- Severity, Dx subtype, potential of biomarkers
- Past response, sensitive to s/e
Tx factors
- Efficacy – effectiveness
- tolerability, simplicity of use, discontinuation syndrome
- safety, potential drug-drug interactions
- Cost, branded vs generic
Management Algorithm
Tx 1st line antidepressant
- No improvement (<20% ↑) or intolerant
- Evaluate s/e and switch to a second agent with evidence for superiority
- (Duloxetine, escitalopram, mirtazapine, sertraline -Zoloft 50-200mg, venlafaxine)
- if less than full remission – augment/combine with another agent
- (Apripiprazole, Lithium, olanzapine, Risperidone)
- Some improvement (>20%) but not in remission
- augment/combine with another agent
- Remission – maintenance therapy – same dose as acute dosage for >6mo after clinical remission (2yr if older, psychotic features, chronic episodes (>2yr of MDE), frequent episodes >2 / 5yr)
Common S/E:
- GI: nausea, diarrhea
- CNS: Headache, insomnia, sedation, nervousness, tremor
- Metabolic: ↑appetite, Wt gain, abn lipid profile, glucose homeostatis
- Monitor in treated pt
- Adverse events: Alter HR & BP; ↑ liver enzymes
- Withdrawal symptoms from abrupt d/c, dose reduction / tapering
- Sexual dysfunction
- Tx w/ dose reduction or switch to another antidepressant
- bupropion, mirtazapine, selegiline
- Tx w/ dose reduction or switch to another antidepressant
Serious adverse effects
- Emergent suicidality in children and adolescents
- shouldn’t discourage initiation of Tx but balance benefits & risk
- Serotonin syndrome or neuroleptic malignant syndrome-like events
- ↑ in SSRIs/SNRIs + MAOi or other serotonergic agents
- ↑upper GI bleeding with SSRIs, especially w/ NSAIDs
- ↑osteoporosis and fractures in the elderly with SSRIs
- Hyponatremia and agranulocytosis
- ↑ seizures with TCAs at therapeutic doses
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