Treating Depression
in the Primary Care Setting
Pharmacologic Interventions
Presented by: Jonathan Betlinski, MD
Date: 09/25/2014
Disclosures and Learning Objectives
• Learning Objectives
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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
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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 up
http://www.nimh.nih.gov/health/publications/depression/index.shtml#pub6
Next comes Sleep Hygiene
www.cci.health.wa.gov.au/docs/Info-sleep%20hygiene.pdf
And Exercise
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3674785/pdf/nihms-386053.pdf
And Behavioral Activation
www.personal.kent.edu/~dfresco/CBT_Readings/BM_Lejuez_BATD_Manual.pdf
Antidepressants are no better than placebo
for mild to moderate depression
http://medicine.plosjournals.org/archive/1549-1676/5/2/pdf/10.1371_journal.pmed.0050045-L.pdf
Pharmacology – Acute Phase
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Choose antidepressant based on
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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
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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
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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 line
http://psychiatryonline.org/pdfaccess.ashx?ResourceID=243261&PDFSource=6
https://www.icsi.org/_asset/fnhdm3/Depr-Interactive0512b.pdf
Pharmacology – Nonresponse
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Reappraise diagnosis
Assess side effects
Assess comorbid conditions
Review psychosocial factors
Check treatment adherence
Check on psychotherapy progress
Consider medication switch vs. augment
http://psychiatryonline.org/pdfaccess.ashx?ResourceID=243261&PDFSource=6
https://www.icsi.org/_asset/fnhdm3/Depr-Interactive0512b.pdf
Pharmacology – Nonresponse - Changing
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Switch to another AD from same class
Switch to an AD from a different class
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Try an SNRI when SSRI not effective
Augment with a different class AD
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Augment with T3
Augment with lithium
Augment with a second-generation
antipsychotic
http://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 depression
http://psychiatryonline.org/pdfaccess.ashx?ResourceID=243261&PDFSource=6
Monitor with PHQ-9 or WHO-DAS
http://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