basics of outpatient depression management chris zamani md
TRANSCRIPT
Epidemiology
• Lifetime prevalence of major depression in the U.S. in 2001 was 16.2%
• Prevalence increases to as much as 20% in patients with a major medical illness.
Recurrence and Recovery
• After one episode the rate of recurrence is 40% over a two year period
• After two episodes the rate is 75% after five years
• 10-30% of patients will have incomplete recovery
Initial evaluation
• H and P• Appropriate lab tests to rule out possible
medical etiology• Screen for suicidal ideation• Screen for severe depression (significant
distress or decrease in function) • Distinguish between unipolar and bipolar
depression
Assessment tool
• Nine item patient health questionaire (PHQ-9)– A score above 20 indicates severe depression– Can be used to measure response to therapy
Non-medical interventions
• More likely to be effective in those with minimal symptoms
• Relaxation techniques• Exercise• Positive activities• Psychotherapy (referral)
– No response after 12 weeks is an indication to start pharmacologic therapy
Pharmacologic management
• Two to three week lag before symptom relief begins
• Early side effects– Nervousness, headache, stomach upset
• Regularly scheduled office visits during initiation
• Goals of treatment are symptom remission
Pharmacologic management
• No clear recommendations for specific antidepressants but guides for agent selection include:– If the patient has been treated successfully by a
particular drug in the past– If a first degree relative has had positive
outcomes with a particular agent– Side effect profile is tolerable by the patient
Antidepressants
• First Generation– MAO Inhibitors– Tricyclic antidepressants
• Side effects– Enhanced sympathetic activity in the presence
of tyramine-containing foods (MAOI)– Dry mouth, blurred vision, constipation, urinary
retention, tachycardia, confusion, delerium (TCA)
Antidepressants
• Second Generation– SSRI
– SNRI
• Side effects– Jitteriness, restlessness, headache, GI Sx, insomnia,
sexual side effects, weight gain (SSRI)
– SNRI has similar profile to SSRI with additional reports of cardiac effects, impairment of glycemic control and liver failure in preexisting liver disease
Antidepressants
• Buproprion has less weight gain and sexual side effects
• Mirtazapine causes more weight gain than SSRIs
Follow-up
• Monitor patient every 1-2 weeks for the first 8 weeks after initiating therapy
• PHQ-9 can be used as a monitoring tool
• Increase dose if there is no response after 2 weeks
• Trial of a different agent if no response at maximum dose for 8 weeks
Follow-up
• Partial responders can be switched to another SSRI, SNRI or buproprion or augmented with buproprion or buspirone
• If two SSRI are ineffective then chamge to a different class
Treatment duration
• After a first episode medication should be taken for at least 6 to 9 months
• Longer duration for those with multiple recurrences
• Discontinue meds with a 2 to 4 week taper• In patients with known psychosocial precipitants
of depression treatment should continue until these underlying factors are eliminated or adapted to.