Treating Depression in the Primary Care Setting Pharmacologic Interventions Presented by: Jonathan Betlinski, MD Date: 09/25/2014

Disclosures and Learning Objectives Learning Objectives – 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 – Acute Phase – Continuation Phase – Nonresponse – Maintenance Phase Next Week's Topic

SIG E CAPS for Depression Ssleep decreased (or increased) Iinterest decreased Gguilt or worthlessness Eenergy decreased Cconcentration difficulties Aappetite disturbance or weight loss Ppsychomotor agitation or retardation Ssuicidal thoughts and depressed mood!

Treatment of Depression in Primary Care Start all treatment with a medical work up Next comes Sleep Hygiene And Exercise And Behavioral Activation Antidepressants are no better than placebo for mild to moderate depression

Pharmacology – Acute Phase Choose antidepressant based on – Prior response (individual or family) – Patient preference – Side effect profile – Safety in overdose – Availability and costs – Drug-Drug interactions – Impacts on co-morbid conditions

Pharmacology – Acute Phase – Initial Most AD's are comparably effective SSRI: citalopram, sertraline, fluoxetine, escitalopram SNRI: venlafaxine, duloxetine, desvenlafaxine, Mirtazapine (sedation, weight gain) Bupropion (weight loss, nicotine cravings)

Pharmacology – Acute Phase – Next 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

Pharmacology – Nonresponse Reappraise diagnosis Assess side effects Assess comorbid conditions Review psychosocial factors Check treatment adherence Check on psychotherapy progress Consider medication switch vs. augment

Pharmacology – Nonresponse - Changing Switch to another AD from same class Switch to an AD from a different class – Try an SNRI when SSRI not effective Augment with a different class AD – Augment with T3 – Augment with lithium – Augment with a second-generation antipsychotic

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 2 nd episode For a third episode For chronic depression Monitor with PHQ-9 or WHO-DAS

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