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).

Assessment
  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.

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
  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

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

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