how to approach the patient with treatment resistant depression (turd) terry l. correll, d.o. chief...
TRANSCRIPT
How to Approach the Patient with Treatment Resistant
Depression (TuRD)
Terry L. Correll, D.O.Chief of Aerospace Psychiatric ConsultationAerospace Medicine Consultation Division
United States Air Force School of Aerospace MedicineClinical Professor of Psychiatry, Boonshoft School of Medicine
Please Select FALSE Statement
1. Dysthymic disorder is re-characterized as persistent depressive disorder in DSM-5
2. Dysthymic disorder used to be called depressive personality disorder in prior DSM’s
3. **Most major depressive episodes are self-limiting and typically resolve within 6-9 weeks
4. Alcohol is a powerful depressant and disruptor of sleep (light, broken sleep)
Please Select FALSE Statement
1. **Depressive disorders tend to improve and often resolve later on in life
2. Depression is comparable to obesity, smoking, inactivity, hyperlipidemia, hypertension, and hostility as a cardiovascular risk factor
3. Healthy lifestyle interventions are equally or more effective treatment for depression compared to antidepressants
4. Chronic use of benzodiazepines or opiates can cause depression.
Treatment Resistant Depression (TuRD)
• I mean no disrespect with this TuRD abbreviation– I try to teach in memorable ways
• TuRD = most challenging patients– High utilizers, somaticizers, “depressive
equivalents”
• TuRD can be avoided
• Most TuRDs are not true TuRDs
• If true TuRD, please refer to mental health
Mood DisordersMood Disorders
• Idiopathic mood disorders– Major depressive disorder– Dysthymic disorder
• Persistent depressive disorder– Bipolar disorder
• Differential diagnosis:– Mood disorder due to a general medical condition– Mood disorder due to a substance– Other mood disorders
• Adjustment disorder with depressed mood• Bereavement (removed in DSM-5)
– Other: Dementia, ADHD, Normal vs. Abnormal Mood
Stahl S M, Essential Psychopharmacology
DEPRESSION
NORMAL MOOD
MANIA
HYPOMANIA
MIXED EPISODE
DYSTHYMIC DISORDER
Major Depressive EpisodeMajor Depressive EpisodeSIG E CAPSSIG E CAPS
2 weeks of 5 or more of the following (one must be dysphoric mood or loss of interests or pleasure)(one must be dysphoric mood or loss of interests or pleasure)
• Sleep disturbance
• Loss of Interests or Pleasure
• Guilt, Rumination (hope/help/worth-lessness)
• Diminished Energy
• Trouble Concentrating or Impaired Memory
• Appetite Disturbance
• Psychomotor Agitation or Retardation
• Suicidal Ideation, Homicidal Ideation
Manic EpisodeManic EpisodeSIG E CAPSSIG E CAPS
1 week ((““Driven by extreme energy like on cocaineDriven by extreme energy like on cocaine””))
• Sleep disturbance
• INCREASED Interests or Pleasure
• NO Guilt, Rumination
• INCREASED Energy
• Trouble Concentrating or Impaired Memory
• Appetite Disturbance
• Psychomotor Agitation
• Suicidal Ideation, Homicidal Ideation
Dysthymic DisorderDysthymic DisorderPersistent Depressive DisorderPersistent Depressive Disorder
Depressed mood for more days than not for at least 2 yrs with 2 (or more) of the following:
• Appetite Disturbance• Trouble Concentrating or Making Decisions• Diminished Energy• Sleep disturbance• Low Self-esteem• Feelings of Hopelessness(social, cognitive, and motivational problems)
Course of (Unipolar) Course of (Unipolar) MajorMajor
Depressive Illness Depressive Illness
MOOD
T I M E
Dysthymic Dysthymic DisorderDisorder
MOOD
T I M E
Double DepressionDouble Depression
MOOD
T I M E
Morbidity and Mortality in Major Morbidity and Mortality in Major DepressionDepression
• Suicide– 10-15%
• Cardiovascular risk– comparable to obesity, smoking, inactivity,
hyperlipidemia, hypertension, hostility
• Cerebrovascular risk
• Poorer self-care, adherence to medical regimen for any medical illness
Stahl S M, Essential Psychopharmacology
acute 6 - 12 weeks
continuation4-9 months
maintenance1 or more years
TIME
DEPRESSION
NORMAL MOOD RELAPSE RECURRENCE
Some General Medical Conditions that May Some General Medical Conditions that May Cause or Mimic DepressionCause or Mimic Depression
• Cardiovascular– infarct, congestive heart
failure
• Endocrine– adrenal insufficiency,
hypothyroidism
• Nutritional– Vitamin B12, D, folate,
thiamine deficiency
• Metabolic– anemia, post-ictal, sleep
apnea, end-stage renal disease, hypercalcemia, hepatitis, hypoglycemia
• Infectious– HIV, encephalitis, aseptic
meningitis, post-viral states, systemic
• Neurodegenerative– Parkinson’s /
Huntington’s
• Tumor– Primary cerebral,
pancreatic CA, systemic neoplasms
Some Drugs that May Cause Some Drugs that May Cause or Mimic Depressionor Mimic Depression
• Corticosteroids
• Anabolic steroids
• Anticonvulsants
• First generation antipsychotics
• Centrally-acting antihypertensives
• Alcohol, sedatives, narcotics/opioids
• Stimulant withdrawal
Treatments for Mood DisordersTreatments for Mood Disorders
• Non-medication remedies
• Psychotherapy
• Light therapy
• Antidepressant medications
• Antidepressant augmentors (adjuncts)
• Electroconvulsive therapy (ECT)
Treatment Resistant Depression (TuRD)Treatment Resistant Depression (TuRD)
Moderate >>>
Treatment Resistant Depression (TuRD)Treatment Resistant Depression (TuRD)
• May be considered TuRD– When not returning to 100% best baseline– After adequate dose, duration, and compliance
• Before labeling patient a TuRD– Reassess diagnosis– Assess medication compliance– Consider overwhelming life struggles/stressors– Consider etiology/exacerbation by medical or
substance abuse conditions
Antidepressant MedicationsAntidepressant Medications• How to select
Antidepressant MedicationsAntidepressant Medications• How to select• Successful/unsuccessful prior trial• Proper dose, duration, compliance,
lifestyle?• Family member’s successful/unsuccessful
prior trial• Strong belief regarding certain treatment• Positive/negative expectation?• Direct to consumer commercials
• Affordabilty
Antidepressant MedicationsAntidepressant Medications
Monoamine Oxidase Inhibitors (MAOIs)– phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid
(Marplan), selegeline patch (Emsam)
Tricyclic Antidepressants (TCAs)– amitriptyline (Elavil), nortriptyline (Pamelor), desipramine
(Norpramin), imipramine (Tofranil), clomipramine (Anafranil)
Selective Serotonin Reuptake Inhibitors (SSRIs)– fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram
(Celexa), escitalopram (Lexapro)
Mixed/Other Mechanism Antidepressants– trazodone (Desyrel), buproprion (Wellbutrin),
venlafaxine (Effexor), mirtazepine (Remeron), duloxetine (Cymbalta), desvenlafaxine (Pristiq)
Antidepressant MedicationsAntidepressant Medications
Monoamine Oxidase Inhibitors (MAOIs)– phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid
(Marplan), selegeline patch (Emsam)
Tricyclic Antidepressants (TCAs)– amitriptyline (Elavil), nortriptyline (Pamelor), desipramine
(Norpramin), imipramine (Tofranil), clomipramine (Anafranil)
Selective Serotonin Reuptake Inhibitors (SSRIs)– fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram
(Celexa), escitalopram (Lexapro)
Mixed/Other Mechanism Antidepressants – trazodone (Desyrel), buproprion (Wellbutrin),
venlafaxine (Effexor), mirtazepine (Remeron), duloxetine (Cymbalta), desvenlafaxine (Pristiq)
Antidepressant MedicationsAntidepressant Medications• Switching antidepressant (ATD)
• After 4 weeks of taking medication regularly without any “toxic distractors” and there is zero improvement• Toxic distractors are life stressors or substance abuse
• Surprising that switching to any reasonable antidepressant will give comparable rates of improvement• Typical to get ~75% response rate with ATD• Typical to get ~50% remission rate with ATD
• Follow up clinical pearl • “What has improved/gone better since we last met?”• “What have you done differently (better – to help yourself)?”
• Validates they are “large and in charge” of their life• They are “driving the bus”
• We are glad to give helpful instructions along the way
Pharmacologic Augmentation Pharmacologic Augmentation StrategiesStrategies
• Second antidepressant• Trazodone
• Lithium• Thyroid (T3) augmentation
– Triiodothyronine
• Stimulants– methylphenidate (Ritalin), dextroamphetamine
(Dexedrine)
• Atypical antipsychotics– risperidone (Risperdal), olanzepine (Zyprexa), quetiapine
(Seroquel), ziprasidone (Geodon), aripiprazole (Abilify)
• Others– buspirone (BuSpar), folate, Omega-3 fatty acids
Electroconvulsive Therapy (ECT)Electroconvulsive Therapy (ECT)• Most efficacious treatment• Most rapid onset of action• Effective for severe depression, mania• May be treatment of choice for severe
depression with psychosis, pregnancy, suicidality, catatonia, geriatrics, multiple medical comorbidities
• Requires general anesthesia• Memory loss, cardiovascular risk• Can be done as outpatient
Other Non-medication Other Non-medication TreatmentsTreatments
• Healthy Lifestyle Interventions
Other Non-medication Other Non-medication TreatmentsTreatments
• Healthy Lifestyle Interventions– Multivitamin/multimineral– Exercise– Deep Breathing– Rest/Relaxation/SLEEP– Prayer/meditation– Participate in healthy spiritual practices, social
relations, meaningful pursuits in life– Fish Oil– Avoid toxins – alcohol, drugs, excessive caffeine,
negative thoughts, people, situations
Light Therapy (Phototherapy)Light Therapy (Phototherapy)
• For Major Depression with Seasonal Pattern (or Seasonal Affective Disorder - SAD)
• Helpful with all types of depression
• Useful in women who are pregnant, nursing
• ~20 minutes daily– Walk outside hand in hand with loved one
• Search for Seasonal Affective Disorder (SAD) bulbs online
Other Non-medication TreatmentsOther Non-medication Treatments
• Decide to create or cultivate positive situations that fulfill your personal needs, encourage growth, and promote self-esteem and self-development
• Become involved with people who have a positive attitude, who share in giving and receiving, and who show their love (find a mentor, growth seeking friends)
• Meaningful Activity/Work/Education/Volunteering:– Find a form of service that contributes to your sense of
purpose and identity
• Schedule humorous and FUN times
Other Non-medication TreatmentsOther Non-medication Treatments
Other Non-medication TreatmentsOther Non-medication Treatments
• Individual psychotherapy• Group therapy• Journaling• Bibliotherapy (Bible, sacred texts, Feeling
Good Book, online reading, Youtube, TED talks…ANY SOURCE they personally select)
• Authentichappiness.org• Goals & Visions for the Future
– Visualize desirable changes there in your life and make goals for working toward them
– Write your goals down and refer to them often
Treatment Resistant Depression (TuRD)
• I mean no disrespect with this TuRD abbreviation– I try to teach in memorable ways
• TuRD = most challenging patients– High utilizers, somaticizers, “depressive
equivalents”
• TuRD can be avoided
• Most TuRDs are not true TuRDs
• If true TuRD, please refer to mental health
Conclusion Conclusion • Depression very common & disabling• Avoid TuRD like the plague• Rule out general medical causes or
substances causing the mood disorder• Assess for mania/hypomania • Maximize antidepressant–Dose and duration–And COMPLIANCE
• Recommend healthy lifestyle interventions• Psychotherapy?
QUESTIONS?QUESTIONS?COMMENTSCOMMENTS
Please Select FALSE Statement
1. Dysthymic disorder is re-characterized as persistent depressive disorder in DSM-5
2. Dysthymic disorder used to be called depressive personality disorder in prior DSM’s
3. **Most major depressive episodes are self-limiting and typically resolve within 6-9 weeks
4. Alcohol is a powerful depressant and disruptor of sleep (light, broken sleep)
Please Select FALSE Statement
1. **Depressive disorders tend to improve and often resolve later on in life
2. Depression is comparable to obesity, smoking, inactivity, hyperlipidemia, hypertension, and hostility as a cardiovascular risk factor
3. Healthy lifestyle interventions are equally or more effective treatment for depression compared to antidepressants
4. Chronic use of benzodiazepines or opiates can cause depression.
Thank you for your Thank you for your time and attentiontime and attention