Domino_5-Minute Clinical Consult, 33e

First page Previous page 55 Next page Last page

Depression

ONGOING CARE

• Supportive psychotherapy: improves self-esteem, psychological functioning, and adaptive skills by focusing on current, problematic relationships or maladaptive patterns of behavior and/or emotional responses. • APA recommends CBT or IPT with second-generation antidepressants if combination therapy is offered (3). MEDICATION Start at the lowest available dose and maintain the highest effectively tolerated FDA-approved dose for at least 4 to 6 weeks before deeming ineffective. Effectiveness is comparable between and within drug classes. Selection should be based on provider famil iarity and patient characteristics/preferences. First Line • SSRIs – Citalopram (Celexa): 20 mg/day; 20 to 40 mg/day; escitalopram (Lexapro): 10 mg/day; 10 to 20 mg/day (both with risk of QTc prolongation) – Fluoxetine (Prozac): 20 mg/day; 20 to 40 mg/day (FDA approved for teens); paroxetine (Paxil): 20–40 mg/day or paroxetine (Parxil-CR) 50–62.5 mg/day; avoid use of both in elderly. – Sertraline (Zoloft): 50 mg/day; 50 to 200 mg/day (associated with higher rates of diarrhea) – Adverse effects: sexual dysfunction, GI upset, dizziness, insomnia, headache, weight gain; typically resolve within the 1st week – Abrupt discontinuation may cause withdrawal symptoms (i.e., dizziness, nausea, headache, paresthesia). • SNRIs – Desvenlafaxine (Pristiq): 25 to 50 mg/day; dulox etine (Cymbalta): 30 to 60 mg/day; venlafaxine XR (Effexor XR): 37.5 to 225 mg/day (higher rate of sexual dysfunction and drowsiness) • Serotonin modulators (starting dose): trazodone (Desyrel): 100 mg/day; vilazodone (Viibryd): 10 mg qHS titrated to 20 mg qHS in week 2 (take with food); vortioxetine (Trintellix): 5 to 10 mg/day; common adverse effects: somnolence, dizziness, constipation/diarrhea, sexual dysfunction • Pregnancy: Most medication are Category C. – Fluoxetine and sertraline are often used but there is an increased risk of pulmonary HTN, mild transient neonatal syndrome of CNS, motor, respiratory, and GI signs if used after 20 weeks’ of gestation. – Paroxetine (Category D): risk of congenital cardiac defects and other anomalies in 1st trimester Second Line • Tricyclic antidepressants (TCAs) – Amitriptyline* (Elavil): 25 to 50 mg every bedtime (qHS); imipramine* (Tofranil): 25 mg qHS or 150 mg/day (serotonin . norepinephrine reuptake inhibitor) – Desipramine* (Norpramin): 25 mg/day; doxepin* (Sinequan): 25 mg qHS up to 150 mg/day – Nortriptyline (Pamelor): 25 mg qHS; (norepinephrine . serotonin reuptake inhibitor) *Drugs that are highly sedating and associated with weight gain

– Relative contraindications: arrhythmias, significant cardiac disease, seizures, osteoporosis, glaucoma – Common adverse effects: orthostatic hypotension, dry mouth, blurred vision, constipation, urinary retention, tachycardia, confusion/delirium • Atypical antidepressants – Bupropion (Wellbutrin): 100 mg BID (dose varies for SR and XL; lower rates of sexual dysfunction) – Mirtazapine (Remeron): 15 mg/day, 45 mg/day (max dose; associated with weight gain, used off-label for appetite stimulation) • Monoamine oxidase inhibitors (MAOIs) – Phenelzine (Nardil): 15 mg/day titrated to 15 mg TID over 2 to 3 days; Selegiline transdermal (Eldepryl): 6 mg patch/24 hr – Allow 14-day period off of all antidepressants before starting MAOIs; common adverse effects: hypotension, sexual dysfunction, sleep disturbance ALERT • Black box warning: increased risk of suicidality in children, adolescents, and young adults who are treated with antidepressants • Serotonin syndrome: rare but potentially lethal complication from rapid increase in dose or addi tion of new medication with serotonergic effects • Antidepressants can precipitate manic episodes in those with bipolar disorder. • Antidepressant discontinuation syndrome: symptoms (FINISH mnemonic): flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal; up to 50% of patients (3) ISSUES FOR REFERRAL Depression complicated by psychosis or treatment resistant depression ADDITIONAL THERAPIES Electroconvulsive therapy for severe refractory depres sion; novel therapies are being developed for major depression and treatment of resistant depression: repetitive transcranial magnetic and deep brain stimulation, ketamine, anti-inflammatory agents, and psilocybin (4). COMPLEMENTARY & ALTERNATIVE MEDICINE • Conditional recommendation for use: exercise monotherapy and St. John’s wort; if neither accept able nor available, consider bright-light therapy, yoga, and adding acupuncture to antidepressant medication. • Insufficient evidence for monotherapy recommen dation: tai chi, acupuncture, omega-3-fatty acids monotherapy, S-adenosyl methionine ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS Admit if there is a risk of harm to self or others.

PATIENT EDUCATION • Medications may take 2 to 4 weeks before benefi cial effect is noted. Recommend exercise, good sleep hygiene, nutrition, and avoid tobacco and alcohol use. • The National Suicide Prevention Lifeline: 800-273-TALK (8255) PROGNOSIS Complete remission is not common; partial remission can be achieved. Relapse is common. REFERENCES 1. Hasin DS, Sarvet AL, Meyers JL, et al. Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry . 2018;75(4):336–346. 2. Maurer DM, Raymond TJ, Davis BN. Depression: screening and diagnosis. Am Fam Physician . 2018;98(8):508–515. 3. Kovich H, Kim W, Quaste AM. Pharmacologic treatment of depression. Am Fam Physician . 2023;107(2):173–181. 4. Marwaha S, Palmer E, Suppes T, et al. Novel and emerging treatments for major depression. Lancet . 2023;401(10371):141–153.