Treatment Strategy Hierarchy Safety: stabilize suicidality, homocidality, self harm, acting out Psychosis: treat aggressively, rule out delirium,

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Presentation transcript:

Treatment Strategy Hierarchy Safety: stabilize suicidality, homocidality, self harm, acting out Psychosis: treat aggressively, rule out delirium, substance induced Substance Induced: treat with detox, benzos, usually resolves in 2-3 days Mania: aggressive antimanic treatment; remember SGAs work quickly, AEDs take > 1 week Depression: 1 year commitment

How to Choose Antidepressants SSRIs Early or initial depression Comorbid anxiety disorders Menstrual or peripartum symptoms Obsessive- compulsive symptoms SNRIs or NE agents Pain ADHD Smoking Treatment failure or resistance Atypical symptoms

How to Choose Antidepressants Antipsychotics/ mood stabilizers Psychotic features Melancholia Mania or mixed state Suiciality Treatment resistance Rapid stabilization Dopamine Agents Treatment resistance Melancholia Cognitive disorders ADHD Certain comorbid medical conditions

Use of Novel Agents Viibryd: SSRI “poopout”, activation, SNRI intolerance Fetzima: Increased need for NE: pain, fatigue, especially sleep disorders, rheumatologic disorders, is enantiomer of Savella Brintellix: geriatics, cognitive disorders, treatment failure Latuda: bipolar depression, psychosis, metabolic syndrome with other SGAs

Special Considerations Food: Viibryd and Latuda require 350 kcal for absorption. Activation: Viibryd AM, Latuda and Saphris PM, Drug interactions: half Wellbutrin dose with Brintellix, no triptans with Brintellix Pain: Fetzima is off label if used only for this Pregnancy: Latuda is category B. All others are C. General: nausea is the primary TRE for all agents. Its worth taking time to enhance compliance. Anti nausea agents can be helpful.

Comorbidities Comorbidities are common with mood disorders. Caveats: – Nothing good happens at 3 am. Stabilize sleep – When in doubt, stabilize it out. SGAs and other meds can be used as a stop gap while waiting for antidepressant effects. – No haldol unless in the ICU. Use IM Geodon or Zyprexa – Benzos, opiates and sedatives will likely worsen depression and should be minimized. – OSA, GERD and diabetes must be stabilized to get remission