Minnesota Psychiatric Society presents

1

• Minnesota Psychiatric Society presents
• Treatment of Depression in the Primary Care
  Setting
• L. Read Sulik, M.D.,
• Medical Director
• Child and Adolescent Psychiatry
• St. Cloud Hospital
• CentraCare Health Plaza
• St. Cloud, MN 56303-5000
• 320-255-5796
• sulikr_at_centracare.com

2
Speaker Declaration

• L. Read Sulik, M.D.
• speakers bureau
• Eli Lilly
• Forest Pharmaceuticals
• Pfizer
• consultant
• Shire
• Jansen

3
Outline

• Depression
• Antidepressants
• FDA Black Box Warning
• What does this mean for providers?
• Next steps for providers
• Next steps for patients/parents/families
• Five levels of Depression Care
• Review of Proposed Depression Management Protocol
• Screening
• Assessment
• Informed Consent Letter
• Medication Management Monitoring Visits
• Communication with therapists
• Consultation / collaboration between primary care
  provider and child and adolescent psychiatrists

4
The Care Process Treatment Approaches for
Depression

• Five Levels of Care
• Watchful Waiting (minimal intervention)
• Psychoeducation
• Primary Care
• Collaborative Care
• Specialized Care

5
Risk and Reoccurrence
Childhood Onset Depression
Adolescent Depression
Later Adolescent Depression
Adult Depression
Birmaher et al., 2002
6
Course of Depression in Youth

• Adults
• Comes and goes with periods of normal mood
• Children and Adolescents
• Chronic waxing and waning, with high risk of
  relapse

Pine et al., 1999
7
DepressionSigns and Symptoms
Behaviors
MEANING
Interpersonal Relationships
School and Job Performance
8
Depression

• A neurochemical illness of the central nervous
  system that often requires medications to achieve
  healing and recovery
• A condition that leads to prominent mood changes,
  sleep and energy changes and changes in the
  thinking
• These changes often lead to interpersonal
  conflict, academic or work performance problems,
  and behavior problems.
• In children and adolescents who are developing in
  numerous ways but most importantly in the area of
  self (who am I?), depression has a profound
  impact on their sense of meaning and their view
  of their world.

9
Depression Mood Changes

• Depressed or sad mood
• Irritable mood
• mood swings
• Anhedonia
• loss of interest
• social withdrawal, isolating
• boredom

10
Depression Physical Symptoms

• Sleep Difficulty either with too much or too
  little sleep
• difficulty with sleep onset
• awakenings in the middle of the night
• early morning awakening
• Increased sleep and sleepiness
• Fatigue
• decreased energy

11
Depression Cognitive Changes

• Worried, Ruminating thoughts
• Worthlessness, low self-esteem, guilt
• Difficulty concentrating
• Decreased attention, focus
• Increased distractibility, daydreaming
• Distortions in thinking
• Red Colored Glasses
• Morbid ideation
• Suicidal ideation

12
Symptoms in Infants and Toddlers

• Decreased pleasure in activities
• Sad or flat facial expression
• Little motor activity
• Withdrawn from cuddling, being held
• Too little or too much crying
• Excessive whining
• Failure to grow and thrive
• Verbal expressions of sadness
• Lack of social interest

13
Symptoms in Preschoolers

• Frequent, unexplained stomachaches, headaches,
  and fatigue
• Overactivity or excessive restlessness
• Frequent sadness
• Low tolerance for frustration
• Irritability
• Loss of pleasure in previously enjoyable
  activities
• Tendency to portray the world
• as sad or bleak

14
Symptoms in School-Aged Children

• Frequent and unexplained physical complaints
• Low self-esteem
• Excessive worrying
• Changes in sleep patterns
• Tearfulness
• Unprovoked hostility or aggression
• Refusal or reluctance to attend school
• Drop in grades
• Little interest in playing with others
• Poor communication
• Thoughts about or efforts to run away
• Morbid or suicidal thoughts

15
Symptoms in Adolescents

• Drop in school grades and/or conduct
• Behavior problems in school
• Feelings of sadness or hopelessness
• Low self-esteem
• Fatigue
• Changes in sleep patterns
• Loss of enjoyment of previously enjoyable
  activities

16
Symptoms in Adolescents

• Self-destructive behavior
• Difficulty with relationships
• Eating-related problems
• Antisocial or delinquent
• behavior
• Social isolation
• Inattention to appearance
• Extreme sensitivity to rejection or failure
• Physical slowness or agitation
• Morbid or suicidal thoughts or actions

17
Suicidal Thoughts

• Suicidal thoughts are a symptom of depression.
• The presence of suicidal thoughts may tell us
  that the depression is increased in severity or
  intensity.
• the presence of wheezing and coughing in a child
  with asthma is a sign that the asthma is
  worsening or flaring up for whatever reason.
• When wheezing is occurring the patient needs to
  let the doctor know so that any further
  assessment or any changes that need to occur to
  relieve the symptoms can.
• Similarly, when an individual begins to
  experience suicidal thoughts the doctor needs to
  know this as soon as possible.
• Children and adolescents dont always volunteer
  that they are having suicidal thoughts so asking
  them these questions is appropriate.

18
Treatment for Depression

• Supportive Therapy and Psychoeducation
• Pharmacotherapy
• Individual Psychotherapy
• Insight Oriented
• Cognitive Behavioral
• Interpersonal
• Play Therapy
• Group Therapy
• Family Therapy
• Hospitalization or Partial Hospitalization

19
Lifestyle Management of Depression

• Sleep
• Diet and Nutrition
• Exercise
• Relaxation
• Support System

• Chemically Free
• Medications
• Therapy
• Fun and Recreation
• Personal Growth

20
Antidepressants
21
Neurotransmitters andMood, Cognition and Behavior
Demonstration
MOOD
Obsessions Compulsions
Alertness
Anxiety
Stahl, Essential Psychopharmacology, 2000
22
Abnormalities of Neurotransmitter Function lead
to
Depressed Mood
Obsessions Compulsions
Decreased alertness Lethargy
Anxiety
Stahl, Essential Psychopharmacology, 2000
23
Antidepressants

• These medications are not only used for
  depression but also commonly used for anxiety
  disorders
• social phobia
• generalized anxiety disorder
• obsessive compulsive disorder
• separation anxiety disorder
• They are not only prescribed for major depressive
  disorder but also for dysthymic disorder (a more
  chronic, intermittent type of depression that
  comes and goes).

24
Antidepressants

• The antidepressants and especially the SSRIs have
  certain characteristics that are very important
  to consider in their use in children and
  adolescents
• Akathisia
• Disinhibition
• Discontinuation Syndrome
• Fast Rate of Metabolism

25
Akathisia

• Many of these medications can cause an increased
  motor restlessness
• Individuals will describe feeling as if they are
  moving inside or crawling out of my skin
• The restlessness can range from finger tapping
  and fidgeting to pacing and agitation.
• As akathisia is increased there can be a feeling
  of increased irritability and agitation or
  aggressiveness.

26
Disinhibition

• Many of these medications can activate or
  disinhibit children making them more impulsive

27
Discontinuation Syndrome

• Physical symptoms such as
• headache
• dizziness
• nausea
• sweating
• Emotional symptoms may involve increased
• irritability
• agitation
• tension
• restlessness
• anxiety

28
Fast Rate of Metabolism

• The shorter the ½ life (the faster the
  metabolism) of the medication, the greater the
  risk of developing a discontinuation syndrome if
  the medication is stopped abruptly.
• Children are often very fast metabolizers of
  these medicines, so the risk of a discontinuation
  syndrome may be much higher.

29
SSRI Pharmacokinetic Parameters
30
SSRI Effects on P450 Enzymes
a Based on in vitro studies, unlikely to have a
clinically meaningful effect. b 150 change in
area under the plasma concentration-time curve
(AUC) of substrate. c 20 to 50 change in AUC of
substrate. d NCS not clinically significant in
most situations lt 20 change in the AUC of a
substrate (ie, concomitantly administered drug)
dependent on that CYP enzyme for its
clearance. e 50 to 100 change in AUC of
substrate. Symbol contradictory in vitro or
in vivo data available.
Preskorn SH. Clin Pharmacokinet. 199732(suppl
1)1-21.
31
Common Side Effects

• Common side effects of antidepressants include
• dry mouth
• constipation
• diarrhea
• sweating
• sleep disturbance
• sexual dysfunction
• irritability
• headache
• appetite changes

32
Adverse Events

• The patient should notify the prescribing
  physician if the following occur
• New thoughts of suicide or a sudden worsening of
  suicidal thoughts
• Any attempts to injure or harm self in any way
• Severely increased motor restlessness
• Severely increased agitation or irritability
• Increased rapid and constant talking (mania or
  hypomania)
• Increased activity level, extreme hyperactivity
• Worsening symptoms of depression
• Increased or new symptoms of anxiety and/or
  panic attacks
• Decreased need for sleep

33
FDA Black Box Warning

• The FDA reviewed data from 24 studies of the use
  of antidepressants in children and adolescents.
• These studies involved the treatment of
  depression or other disorders such as Obsessive
  Compulsive Disorder or Generalized Anxiety
  Disorder.
• There were a total of 4400 children or
  adolescents in these studies that had been
  randomly assigned to take the antidepressant or
  to take a sugar pill (placebo).

34
FDA Black Box Warning

• The antidepressants included the SSRIs (Celexa,
  Prozac, Luvox, Paxil and Zoloft) and four
  "atypical" antidepressants (Wellbutrin, Remeron,
  Serzone and Effexor XR).
• The length of time of the studies ranged from 1
  to 4 months.
• About 2 out of every 100 individuals taking the
  placebo reported an increase of suicidal
  thoughts. About 4 out of every 100 individuals
  taking one of the antidepressants in the studies
  had an increase of suicidal thoughts and
  behaviors.
• There were no completed suicides in any of the
  studies.

35
Call for Close Monitoring

• The warning does not prohibit the use of
  antidepressants in children and adolescents.
• The FDA has recommended that whenever an
  antidepressant is started or its dose is changed,
  close attention is needed.
• Since the warning was first announced, the FDA
  has been more specific about the recommendation
  for closer monitoring.
• After starting an antidepressant, patients should
  see their doctor
• Once a week for four weeks
• Every 2 weeks for the next month
• At the end of their 12th week taking the drug
• More often if problems or questions arise

36
TADS

• Even though this type of follow-up is being
  recommended for safety reasons, there is evidence
  that very close monitoring in this manner may
  lead to improved outcomes in treatment.
• The National Institute of Mental Health Treatment
  of Adolescent Depression Study (TADS) was a
  multi-site study looking at the effect of
  fluoxetine (Prozac) with or without Cognitive
  Behavioral Therapy
• TADS demonstrated that fluoexetine when
  prescribed and monitored closely (weekly visits)
  was more effective than cognitive behavioral
  therapy alone and about equally effective as
  cognitive behavioral therapy and medication
  combined.

37
Provider Next Steps

• A structured frequent follow-up visit to monitor
  for changes in symptoms and also for presence of
  adverse effects of medications will not only meet
  the recommended guidelines for monitoring but
  ultimately improve care and outcomes.
• Collaboration, consultation and ongoing
  communication between primary care providers,
  child and adolescent psychiatrists and therapists
  is another way to assure good monitoring and
  improved care.
• Parents and professionals will need to improve
  their awareness of potential adverse events and
  improve their communication with the physician
  prescribing the medication.

38
Parent / Family Next Steps

• The most important thing that parents can do is
  to learn as much as they can about depression in
  children and adolescents.
• Know the medication that is being prescribed to
  their child.
• Be able to ask questions about adverse effects
  and how to recognize them.
• If the child begins to experience the following,
  than the physician should be contacted
  immediately
• New thoughts of suicide or a sudden worsening of
  suicidal thoughts
• Any attempts of your child to injure him or
  herself in any way
• Increased motor restlessness
• Increased agitation or irritability
• Increased rapid and constant talking (mania or
  hypomania)
• Increased activity level, extreme hyperactivity
• Worsening symptoms of depression
• Increased or new symptoms of anxiety and/or
  panic attacks
• Difficulty sleeping

39
Screening
40
Screening Tools

• Screening tools for depression (self-report or
  provider administered)
• Zung Depression Scale
• Symptom Driven Diagnostic System (SDDS)
• Hamilton Reference Scale
• Prime MD, PHQ 9
• Others

41
Screening Tools for Adults PHQ-9

• Patient at intake presents with symptoms
  consistent with a primary diagnosis of Major
  Depressive Disorder or Depression NOS.
• MD/APP, nurse or therapist administers the PHQ-9.
  The PHQ-9 triggers one of the following
  interventions
• A score of 20 Medications and therapy
  strongly recommended.
• MD/APP Intake If the patient does not already
  see a therapist, recommend patient schedule a
  therapy appointment within one week
• Therapist Intake Recommend patient schedule with
  primary care or behavioral health MD/APP within
  one week for medication.
• A score of 10 - 19 Medications and/or therapy
  are strongly recommended.
• Follow up appointment to be made within four to
  six weeks.
• A score of lt10 or depression not primary
  diagnosisTreat as usual.
• 3. PHQ-9 is reviewed with the patient and the
  process of patient education is begun. An initial
  plan of intervention is discussed. The patient
  will be provided with information from the Hope
  and Help for Depression booklet.

42
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43
Assessment
44
Assessment

• Interview of Patient and Parent/Caregiver
• Mood Changes
• Sleep, Energy, Appetite Changes
• Cognitive Changes
• Safety Assessment
• Comorbid Conditions and Differential Diagnosis
• Family History
• Self-Report Instruments
• Childrens Depression Inventory
• Beck Depression Inventory

45
Assessment of Mood Changes

• Sadness
• Irritability
• Anhedonia

46
Assessment of Sleep/Energy/Appetite Changes

• Insomnia
• Disrupted or Restless sleep
• Daytime fatigue
• Decreased appetite and weight loss
• Increased appetite and weight gain
• Psychomotor retardation or psychomotor agitation

47
Assessment of Cognitive Changes

• Inattentiveness
• Poor concentration
• Distortions and misinterpretations
• Guilt or worthlessness

48
Assessment of Safety

• Suicidal Thoughts
• History of Suicide Attempts
• Access to medications, firearms
• Self-injurious behaviors

49
Comorbid Conditions and Differential Diagnosis

• Substance Abuse
• Eating Disorders
• Anxiety Disorders
• ADHD
• Bipolar Disorder
• Trauma
• Physical Abuse
• Sexual Abuse
• Exposure to Domestic Violence

50
Assessment of Family History

• Depression
• Anxiety
• Bipolar Disorder
• Suicide

51
Self-Report Measures

• Beck Depression Inventory
• Childrens Depression Inventory

52
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53
Three Visit Minimal Intervention Protocol
54
The Three Visit Minimal Intervention Model

• First Visit
• Once depression is suspected and determined it is
  not Major Depressive Disorder
• Second Visit
• Avoid tendency to expect improvement or suggest
  that patient must be better
• Third Visit
• Assess problem for resolution to the point of
  return to reasonable function vs need for more
  active therapy

55
Minimal Intervention First Visit

• Actively invite the patient to describe the
  problem
• Disturb the normal tendency to suggest that
  feeling blue is irrational
• Touch the patient. Do a focused physical exam,
  minimal laboratory tests if indicated
• Establish a contract for follow-up in 2 weeks

56
Minimal Intervention Second Visit

• Open the second visit with social comment
• Begin the discussion in a non-directive manner
• Review any remaining medical/laboratory issues
• Disturb the tendency to cheerleading or telling
  patient everything will soon be better - Listen
• Establish contract for third visit 2 weeks later

57
Minimal Intervention Third Visit

• Open with social comment and await spontaneous
  report by patient regarding improvement or
  worsening of depressed mood
• Directly inquire about the depressed mood
• Evaluate for further treatment or end of limited
  interview

58
Desired Outcomes for Minimal Intervention

• Self-directed improvement by the patient
• Case is flagged for nurse review and follow-up
  after three months (research options)
• Minimal increase in medical problems
• If clinical depression is identified as a result
  of the screening, higher levels of care are
  pursued

59
Psychoeducational Intervention Protocol
60
Psychoeducational Intervention Appropriate for

• Subclinical level of symptoms
• Minimal to moderate psychosocial stress
• Minimal disruption of daily functioning
• Acknowledgment of symptoms, concerns, or need for
  information by the patient

61
Psychoeducational Intervention

• Depression Class
• Biblio-therapy
• Explanation of depression for patient and family
  by physician or mental health professional

62
Goals of Psychoeducational Intervention

• Plan is documented in the patients medical chart
• Provider is notified when patient has completed
  the class
• Post-class telephone follow-up by nurse/MD
• Patient has increased knowledge about depression
  and self care
• Patient reports increase in self-care
• Provider maintains focused monitoring of risk
  factors and depressive symptoms

63
Information for Patients

• Depression is a medical illness, not a character
  defect
• Recovery is the rule, not the exception
• Treatment is effective for nearly all patients
• The aim of treatment is complete remission, not
  just getting better but staying well
• The risk of recurrence is significant
• 50 after one episode
• 70 after two episodes
• 90 after three episodes

64
Possible Resources for Management of
Mild/Moderate Depression

• Patient activation tools
• Books, pamphlets, community groups
• Screening tools for depression (self-report or
  provider administered)
• Zung Depression Scale
• Symptom Driven Diagnostic System (SDDS)
• Hamilton Reference Scale
• Prime MD, PHQ 9
• Others

65
Resources for Management of Mild/Moderate
Depression

• Patient educational materials readily available
  during encounter
• Provider training, as needed, in differential
  diagnosis of depression, including use of
  diagnostic tools, in patient-provider
  communication regarding psychosocial issues and
  in use of psychotropic medications
• Ability to reassess patient progress in 3-6 weeks
• Psychiatric consultation regarding medication
  issues
• Mental Health professional in primary care clinic
  or available by phone

66
Desired Outcomes

• Clinical tracking in medical chart (problem list
  and diagnosis) leading to monitoring and focused
  care
• Improved symptoms and daily functioning
• Medication management by physician and/or
  psychiatric nurse
• Increased readiness for mental health
  collaboration, as needed

67
Primary Care Physician Management of
Moderate/Major Depressive Disorders

• Subclinical or clinical level of symptoms
• Minimal to moderate psychosocial stress
• Mild to moderate disruption of daily functioning
• Acknowledgment of symptoms, concerns, and need
  for treatment by the patient
• Patient not ready for mental health collaboration
  or referral

68
Primary Care Depression Management Protocol
69
Depression Monitoring Visits

• Clinic Visits week 1, 2, 3, 4, 6, 8 , 12
• Phone Contact
• Symptom Review
• Medication Compliance
• Adverse Effects
• Safety Assessment
• Self-Report Scales

70
Symptom Review

• Sad Mood
• Irritability
• Anhedonia
• Increased motor activity
• Sleep problems
• Decreased motor activity
• Appetite or Weight Change
• Fatigue

71
Behavior Symptoms

• alcohol use
• illicit drug use
• angry or violent outbursts

72
Medication Compliance

• no doses missed
• one or two doses missed
• 3 or more doses missed

73
Adverse Events

• dry mouth
• insomnia
• appetite change
• constipation
• disrupted sleep
• weight change
• diarrhea
• sexual dysfunction
• Sweating
• headache

74
Safety Assessment

• suicidal thoughts
• suicide intent
• self-injurious thoughts
• suicide plan
• suicide attempt
• self-injurious behaviors

75
Depression Self-Care Discussion and Teaching

• Sleep
• Diet and Nutrition
• Exercise
• Relaxation
• Support System
• Chemical Use
• Medications
• Therapy
• Recreation
• Goals and Growth

76
Communication with Therapists

• HIPAA-compliant ROI form signed at each visit at
  front desk as standard protocol
• Establish communication protocol at same interval
  as monitoring visits
• Week 1, 2, 3, 4, 6, 8, 12
• Establish communication documentation form that
  is used by therapists and by primary care
  providers

77
Consultation Protocol

• Establish Collaboration / Consultation Protocol
  between Child and Adolescent Psychiatrists and
  Primary Care Provider
• Curbside Consult may occur on average of once
  per 12 week monitoring interval
• Triage patients at high acuity level to
  emergency child psychiatric appointments
• Primary care providers may need to do some of the
  monitoring visits so that child psychiatrists
  are more available for the emergency appointments
• Consider Mental Health Professional in Primary
  Care Clinic for triage assessments, consultation,
  patient and parent teaching

78
Collaborative Care Depression Protocol
79
Primary Care/Mental Health Professional
Collaborative Care for Major Depressive Disorder

• When is it most helpful?
• Subclinical to clinical level of symptoms
• Moderate to severe psychosocial stress
• Moderate to severe disruption of daily functioning

80
Collaborative Intervention

• Case sharing within mental health and primary
  care provider team
• Clinical focus on improvement in patient coping
  and problem-solving, including mental health
  consultation and on-site mental health treatment
  is ideal
• Psychotropic medication, as indicated, managed in
  primary care

81
Desired Outcomes for Collaborative Care of
Depression

• Clinical tracking in medical chart (problem list
  and diagnosis)
• Focused care for both patient and provider,
  leading to clarification in provider roles and
  change in pattern of medical utilization
• Clinical effectiveness in treatment of depression
• Improved patient and provider satisfaction

82
Additional Resources Needed for Collaborative
Care

• Appropriately trained mental health provider
  within primary care team
• Appropriately trained primary care physician with
  interest and motivation for collaborative efforts
  with mental health clinicians
• Space, shared access to medical record
• Economic system that values collaborative effort

83
Specialty Care
84
Benchmarks for When to Consult/Refer

• Immediate risk of suicide
• Panic disorders when somatic symptoms accelerate
  to frequent ER visits, weekly medical visits
• Any patient not improving after 3-6 visits
• Any time physician is angry or upset repeatedly

85
Specialty Care of Major Depressive Disorder

• Clinical level of symptoms
• Moderate to severe psychosocial stress
• Moderate to severe disruption of daily
  functioning
• Perceived need for mental health services by both
  patient and provider

86
Specialist Intervention for the Treatment of
Depression

• Referral (hand-off) to mental health by primary
  care
• Focused psychosocial interventions, including
  clinical focus on improvement in patient coping
  and problem-solving, unpacking of psychosocial
  issues, or other specialized treatments
  (outpatient, day-treatment, partial-hospital,
  inpatient care), as needed
• Psychotropic medication, as indicated, managed by
  specialty or primary care provider

87
Desired Outcomes for Specialized Care

• Clinical tracking in mental health chart (problem
  list and diagnosis)
• Clinical effectiveness in treatment of depression

88
Additional Resources Needed for Specialized Care
of Depression

• Full range of specialty mental health providers
  and programs
• Access to the mental health team

89
What are the medications that treat depression
and how do they work?
90
Antidepressants

• Selective Serotonin Reuptake Inhibitors
• Prozac, Zoloft, Paxil, Luvox, Celexa, Lexapro
• Atypical Antidepressants
• Effexor
• Serzone
• Remeron
• Welbutrin
• Cymbalta

Demonstration
91
The Not So Selective SSRIs

• Fluoxetine
• serotonin 2C
• Sertraline
• dopaminergic
• sigma
• Paroxetine
• anticholinergic
• NE
• Fluvoxamine
• sigma
• Citalopram
• selective

• All SSRIs have serotonin reuptake inhibition
• All have different secondary pharmacological
  properties
• Secondary actions distinguish one from the other

Stahl, Essential Psychopharmacology, 2000
92
Dopamine Transporter Affinity
Richelson E. Mayo Clin Proc 1994
93
Fluoexetine (Prozac)

• Causes appetite suppression and weight loss
  initially
• Not well tolerated when initiating treatment in
  panic disorder
• Better efficacy in bulimia and binge eating
• Advantageous in those with psychomotor
  retardation and hypersomnia
• Poorly tolerated in those with psychomotor
  agitation/anxiety/insomnia
• May cause more undesirable activating side
  effects
• May worsen psychotic depression
• Prozac Weekly (90 mg capsule) only extended
  release SSRI available

Stahl, Essential Psychopharmacology, 2000
94
Sertraline (Zoloft)

• Possible improvement in cognitive
  function/sustained attention in some patients
• Reduction of fatigue, apathy, and psychomotor
  retardation
• Less prolactin elevation its consequences
• Might cause more psychomotor agitation, anxiety
  or insomnia in some patients
• Might be less well tolerated in patients with
  anxiety
• May necessitate more dose titration in anxious
  patients
• Short half-life may require dosing twice a day

Stahl, Essential Psychopharmacology, 2000
95
Paroxetine (Paxil)

• Anxiety (short term)
• Anxiety disorder subtypes (panic, OCD, social
  phobia
• 2D6 concomitant drugs
• Withdrawal
• Inhibition of both SERT and NET by paroxetine may
  underlie its broad therapeutic range
• high-dose paroxetine treatment may be beneficial
  for patients who fail to respond to treatment
  with another SSRI or lower doses of paroxetine
• Paxil CR
• Controlled release form now available
• Less GI side effects

Stahl, Essential Psychopharmacology, 2000
96
Fluvoxamine (Luvox)

• sertraline, fluvoxamine may have increased GI
  complaints
• sertraline,fluvoxamine effective in delusional
  depression
• Antipsychotic actions? Anxiolytic actions?
• Anxiety (short term)
• OCD
• Psychotic depression?
• Shorter half life (bid)
• Sedation
• GI side effects/irritable bowel syndrome
• 1A2, 3A4 drugs

Stahl, Essential Psychopharmacology, 2000
97
Citalopram (Celexa)

• No significant drug interactions
• No significant activation/Anxiety/Insomnia
• ? rapid onset
• ? less sexual dysfunction
• Does not have secondary pharmacologic properties
  which may be desirable in some patients
• Estalopram (Lexapro)
• Estalopram (Lexapro) is an isomer of citalopram
• 10mg/day demonstrated comparable efficacy to
  40mg/day of Celexa
• Shorter half-life in children and adolescents may
  require twice a day dosing

Stahl, Essential Psychopharmacology, 2000
98
Atypical Antidepressants

• nefazadone (Serzone)
• Serotonin
• 5HT2 blockage
• Association with liver failure (rare)
• trazadone (Desyrel)
• Serotonin
• 5HT2 blockage
• venlafaxine (Effexor)
• Serotonin
• NE
• Dopamine (in high doses)
• buproprion (Welbutrin)
• Dopamine
• Norepinephrine
• mirtazapine (Remeron)
• Serotonin
• NE
• duloxetine (Cymbalta)
• Serotonin

99
Tricylic Antidepresants

• Use TCAs with caution
• sedation
• weight gain
• dry mouth
• constipation
• risk of sudden death (monitor blood levels with
  EKGs)

Stahl, Essential Psychopharmacology, 2000
100
Summary of Medications for Depression

• Begin treatment with SSRI
• activating SSRI for melancholic depression or
  vegetative depression
• activating SSRI may increase anxiety
• watch for and warn parents about akathisia and
  disinhibition in children
• watch for and warn about withdrawal syndromes in
  short half-life SSRIs
• be aggressive in regulating sleep

101
Summary

• Depression consists
• of a change in mood
• sadness
• irritability
• anhedonia
• physical symptoms
• cognitive symptoms
• Depression is a mood disorder AND a sleep and
  energy disorder AND a thinking disorder
• To the patient depression is a severe,
  debilitating condition leading to severe
  suffering. . . but treatment is effective and no
  one should continue to suffer without help
• Treatment must address the biological,
  psychological, social and spiritual aspects of
  the illness

102
How can primary care clinic design support
quality psychiatric care?

• Integrated care
• Shared Care
• Consultation-liaison
• Clinical Nurse Specialists, Physician Assistants,
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