The Basics of Safely Prescribing SSRIs/SNRIs & Other Medications for Depression and Anxiety

Symptoms with Job Corps Students

David Kraft, MD, MPH

Boston Regional Mental Health Specialist

Outline

• Overview of psychotropic drugs• Diagnostic categories (DSM-5)• Clinical indications (e.g., starter doses,

follow-up doses, etc.)• Black box warnings• Side effects• Indications and strategies to stop

medications • Ongoing frequency of follow-up• Drug interactions

Overview• Most frequent mental health problems in

Job Corps where medications are prescribed are depression and anxiety issues.

• The next most common problem is ADHD at many centers.

• Most frequent psychoactive medications with Job Corps youth are antidepressants, which are also good for anxiety issues.

Overview (continued)

• Fewer students will require other psychotropic medications, such as are used with Bipolar Disorder, Schizophrenia, and other disorders– Usually such students will arrive already on

these medications, so the Center Physician may only be asked to continue the prescriptions

– Many Job Corps centers are not located near a psychiatric clinic or provider who can prescribe for the student while on center

Diagnostic Symptoms of Depression (DSM-5)

• Criteria for Depression (5 of 9 symptoms)– Depressed mood nearly every day– Decreased interest/pleasure in activities– Significant change in weight (not trying +/-)– Insomnia or hypersomnia most days – Psychomotor agitation or retardation– Fatigue/loss of energy most every day– Feelings worthlessness/excessive guilt– Reduced ability to think or concentrate– Recurrent thoughts of death/suicidality

Depression Symptoms (continued)

• Symptoms cause clinically significant distress or impairment

• Episodes not due to physiological effects of a substance or another medical condition

• Other Depressive Diagnoses– Persistent Depressive Disorder (Dysthymia)– Premenstrual Dysphoric Disorder– Substance/Medication Induced Depression

Diagnostic Symptoms of General Anxiety Disorders

• Worry about specific situation for at least 6 months, plus 3/6 symptoms:– Restlessness, all keyed up– Being easily fatigued– Trouble concentrating or mind goes blank– Irritability– Muscle tension– Sleep disturbance

• Treat with Psychotherapy plus Meds– Cognitive Behavioral Therapy, Relaxation,

Rebreathing, Meditation

Diagnostic Symptoms of Other Anxiety Disorders

• Specific Phobia and Social Phobia• Panic Disorder• Agoraphobia (marked fear/anxiety about

not being able to avoid dangers)• Obsessive Compulsive Disorder and

Related Disorders• Post-Traumatic & Acute Stress Disorder• Eating Disorders

General Principles

• Most medications take 1-2 weeks to work effectively (absorbed in GI tract, then transferred to cerebrospinal fluid in brain to begin working)

• Side-effects often noticed shortly after taking medication (mainly in blood in sufficient levels)

• Some side-effects can be useful, e.g. sedation if someone has trouble getting to sleep

• Most antidepressants are good for treating anxiety disorders as well

General Principles in Job Corps

• Most students on medications when they arrive will want to stay on the medication during their training.

• Consult with the Center Mental Health Consultant (CMHC) when a student seems to need an adjustment in one of his/her medications.

• Major changes in medication should be done during vacations, if possible.

Clinical Indications

• Major Depression (single and recurrent types, not Bipolar)

• Severe Anxiety Disorders, e.g. Obsessive Compulsive Disorder

• Sleep hygiene, not complicated, though may need to add sedating antidepressant (e.g. trazodone) and follow

Dosing: SSRIsMedication (generic/trade)

Starting dose Usual dose Category

citalopram(Celexa)

10 mg qd 20-40 mg qd SSRI

escitalopram(Lexapro)

10 mg qd 10-20 mg qd SSRI

fluoxetine(Prozac)

10 mg qam 20-60 mg qd SSRI

fluvoxamine(Luvox)

50 mg qd 100-300 mg qd SSRI

paroxetine(Paxil)

10 mg qhs 20-60 mg qd SSRI

sertraline(Zoloft)

25 mg qd 50-200 mg qd SSRI

trazodone(Desyrel)

25 mg qhs 25-150 mg qhs SSRI

Half-Life, Features, and Side Effects (SSRIs)

Generic (Brand) Half-Life Features Side-effects

fluoxetine (Prozac)

60 hrs •Stimulating, not sedating•Used for OCD, depression, once a day dosing

GI upset

sertraline (Zoloft)

26 hrs •Increased plasma level with food•Used for depression and anxiety, has a more linear dose/response relationship than other SSRIs

Sexual side effects

citalopram(Celexa)

35 hrs Not as good with high levels of anxiety

Sedation may impede higher dosing

Half-Life, Features, and Side Effects (SSRIs)

Generic (Brand) Half-Life Features Side-effects

escitalopram(Lexapro)

35 hrs •2x stronger by dose than citalopram

Fewer side effects than citalopram

fluvoxamine(Luvox)

15.6 hrs •Given in divided doses•Known for being approved for ObsessiveCompulsive Disorder, though not really better than other SSRIs

Some weight gain

paroxetine(Paxil)

26 hrs More sedative side effects and weight gain

Dosing: SNRIsMedication (generic/trade)

Starting dose Usual dose Category

venlafaxine(Effexor)

25 mg qd 75-375 mg qd SNRI

duloxetine(Cymbalta)

20 mg qd 60-120 mg qd SNRI

desvenlafaxine(Pristiq)

50 mg qd 50-100 mg qd SNRI

Half-Life, Features, and Side Effects (SNRIs/NDRI)

Generic (Brand) Half-Life Features Side-effects

desvenlafaxine (Pristiq)

9-11 hrs •Well absorbed from GI tract•Studies have shown that SNRI treatment of both outpatients with major depression and inpatients with melancholia have proven better than treatments with SSRIs and other agents

Monitor BP

duloxetine (Cymbalta)

12 hrs •Superior results with Generalized Anxiety Disorder (GAD)•Studies of SNRIs with various anxiety disorders and pain conditions seems to be improving treatment options that used to be responsive to tricyclic antidepressants (TCAs), but with fewer side effects.

Not tolerated as well as SSRIs

venlafaxine(Effexor)

4-6 hrs •Superior results with chronic pain, with fewer side effects than TCAs

Not tolerated as well as SSRIs

bupropion (Wellbutrin)

9.8hrs •norepinephrine-dopamine reuptake inhibitor (NDRI), rapid absorption, metabolized by liver (use carefully if liver damage is evident), usual starter dose 100mg in AM; daily doses 100-450mg daily

Other Common Agents

• Older agents (e.g., tricyclic antidepressants & MAOIs) not used without consultation with Specialist

Black Box Warnings

• Increased risk of suicidal thinking and behavior in children, adolescents, and young adults taking antidepressants

• Monitor for worsening and emergence of suicidal thoughts and behaviors, especially during the first two weeks of treatment

Black Box Warnings• Antidepressants increased the risk compared

to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders.– Risk limited to persons under 24 years– Worse in first 10-14 days of treatment in

most studies– May take at least 1 month to work– Suicidality NOT the same as suicide

Indications to Stop Medications

• Unacceptable side effects after 5 days. (Usually, mild sedation or activation disappears in a few days).

• Occurrence of mania/hypomanic symptoms when not already on Mood Stabilizers (lithium, divalproex, carbamazepine).

• Staff or other students complain about risky behaviors, different from behavior before medication.

• Report of suicidal ideas or plans (probably needs MSWR or hospitalization if concern about suicide).

Stopping Medications

• When someone stops their psychotropic medications, it usually takes at least 5 days to get out of their system.– Most meds need to be tapered, to avoid

withdrawal symptoms.– Exceptions to these general rules include

stimulants and “benzos” (benzodiazepines), which work quickly and can usually be stopped quickly, though tapering is better.

Drug Interactions

• SSRIs/SNRIs are generally safe and effective after at least 2 weeks

• Starting dose often all that is needed• A few students treated with TCAs will

need added side effect meds.* • Students on MAOIs need careful

monitoring to avoid dietary side effects.*• Most other medications can be safely

taken with usual SSRI/SNRI treatment..

*Consultation indicated.

Ongoing Follow-up• Students should be monitored by the center

physician (CP), CMHC, and health and wellness staff.

• If current medicine is not working– CP may consult with CMHC and adjust meds– Refer for consult with psychiatrist in community,

if available– Refer back to original prescriber via leave or

during breaks – MSWR should be considered if student is

having acute symptoms interfering with participation in program

References• Black, DW, & Andreasen, NC. (2014). Introductory

Textbook of Psychiatry (sixth edition). Arlington, VA: American Psychiatric Publishing, a Division of the American Psychiatric Association.

• Maxmen, JS, Kennedy, SH, & McIntyre, RS. (2008). Psychotropic Drugs: Fast Facts, Fourth Edition. New York: WW Norton & Company, Inc.

• Schatzberg, AF, & DeBattista, C. (2015). Manual of Clinical Psychopharmacology, Eighth Edition. Arlington, VA: American Psychiatric Publishing, a Division of the American Psychiatric Association.