Depression – CANMAT Guideline 2009

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).

  1. Suicidality
  2. Bipolarity
  3. Comorbidity & concomitant medications
  4. Special features (psychosis, atypical features, seasonality)
  5. 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
    1. Feeling down, depressed or helpless?
    2. 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.

  • 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).

  • Reactive mood, over sleeping, over eating, leaden paralysis, interpersonal rejection, sensitivity
  • 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
  • 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
  • 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
  • individualized based on symptom profile, comorbidity, tolerability, previous response, potential interactions, pt preference, cost
1st line: CBT & IPT
  1. 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)
  2. SNRI (Venlafaxine – effexor 75-275mg & Duloxetine – cymbalta 60-120mg)
  3. NDRI (Bupropion – wellbutrin 150-300mg)
  4. α2 adrenergic agonist & 5-HT2 antagonist (Mirtazapine – remeron 30-60mg)

2nd line:

  1. TCAs (Amitriptyline), MAOi (Selegiline – emsam),
  2. SRI/5-HT2 antagonist (trazodone),
  3. Atypical antipsychotic (quetiapine XR)
    • MDD + psychotic features, Tx w/ antidepressants + antipsychotic

Pt factors:
  1. Age & sex & comorbid disorders
  2. Severity, Dx subtype, potential of biomarkers
  3. Past response, sensitive to s/e
Tx factors
  1. Efficacy – effectiveness
  2. tolerability, simplicity of use, discontinuation syndrome
  3. safety, potential drug-drug interactions
  4. Cost, branded vs generic

Management Algorithm

Tx 1st line antidepressant

  1. 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)
  2. Some improvement (>20%) but not in remission
    • augment/combine with another agent
  3. 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:
  1. GI: nausea, diarrhea
  2. CNS: Headache, insomnia, sedation, nervousness, tremor
  3. Metabolic: ↑appetite, Wt gain, abn lipid profile, glucose homeostatis
    • Monitor in treated pt
  4. Adverse events: Alter HR & BP; ↑ liver enzymes
  5. Withdrawal symptoms from abrupt d/c, dose reduction / tapering
  6. Sexual dysfunction
    • Tx w/ dose reduction or switch to another antidepressant
      • bupropion, mirtazapine, selegiline

Serious adverse effects
  1. Emergent suicidality in children and adolescents
    1. shouldn’t discourage initiation of Tx but balance benefits & risk
  2. Serotonin syndrome or neuroleptic malignant syndrome-like events
    • ↑ in SSRIs/SNRIs + MAOi or other serotonergic agents
  3. upper GI bleeding with SSRIs, especially w/ NSAIDs
  4. osteoporosis and fractures in the elderly with SSRIs
  5. Hyponatremia and agranulocytosis
  6.  seizures with TCAs at therapeutic doses

Posted in 24 Depression, 99 Priority Topics, FM 99 priority topics, Psych

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