1. Basics of outpatient depression management Chris Zamani MD

2. Epidemiology Lifetime prevalence of major depression in the U.S. in 2001 was 16.2% Prevalence increases to as much as 20% in patients with a major medical illness.

3. Recurrence and Recovery After one episode the rate of recurrence is 40% over a two year period After two episodes the rate is 75% after five years 10-30% of patients will have incomplete recovery

4. Initial evaluation H and P Appropriate lab tests to rule out possible medical etiology Screen for suicidal ideation Screen for severe depression (significant distress or decrease in function) Distinguish between unipolar and bipolar depression

5. Assessment tool Nine item patient health questionaire (PHQ-9) –A score above 20 indicates severe depression –Can be used to measure response to therapy

6. Non-medical interventions More likely to be effective in those with minimal symptoms Relaxation techniques Exercise Positive activities Psychotherapy (referral) –No response after 12 weeks is an indication to start pharmacologic therapy

7. Pharmacologic management Two to three week lag before symptom relief begins Early side effects –Nervousness, headache, stomach upset Regularly scheduled office visits during initiation Goals of treatment are symptom remission

8. Pharmacologic management No clear recommendations for specific antidepressants but guides for agent selection include: –If the patient has been treated successfully by a particular drug in the past –If a first degree relative has had positive outcomes with a particular agent –Side effect profile is tolerable by the patient

9. Antidepressants First Generation –MAO Inhibitors –Tricyclic antidepressants Side effects –Enhanced sympathetic activity in the presence of tyramine-containing foods (MAOI) –Dry mouth, blurred vision, constipation, urinary retention, tachycardia, confusion, delerium (TCA)

10. Antidepressants Second Generation –SSRI –SNRI Side effects –Jitteriness, restlessness, headache, GI Sx, insomnia, sexual side effects, weight gain (SSRI) –SNRI has similar profile to SSRI with additional reports of cardiac effects, impairment of glycemic control and liver failure in preexisting liver disease

11. Antidepressants Buproprion has less weight gain and sexual side effects Mirtazapine causes more weight gain than SSRIs

12. Follow-up Monitor patient every 1-2 weeks for the first 8 weeks after initiating therapy PHQ-9 can be used as a monitoring tool Increase dose if there is no response after 2 weeks Trial of a different agent if no response at maximum dose for 8 weeks

13. Follow-up Partial responders can be switched to another SSRI, SNRI or buproprion or augmented with buproprion or buspirone If two SSRI are ineffective then chamge to a different class

14. Treatment duration After a first episode medication should be taken for at least 6 to 9 months Longer duration for those with multiple recurrences Discontinue meds with a 2 to 4 week taper In patients with known psychosocial precipitants of depression treatment should continue until these underlying factors are eliminated or adapted to.

15. Sources Katon, W. and Ciechanowski, P. “Initial treatment of depression in adults” Up To Date online 2009