Antidepressant Medications

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Antidepressant Medications
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Supporting Antidepressant Management

• Become familiar with commonly used antidepressant
  medications medication doses
• Provide basic patient education about
  antidepressants
• Support antidepressant medication adherence
• Know when treatment is not working

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Supporting Antidepressant Management

• Help patients and providers identify
• - Potentially inadequate doses
• - Ineffective treatment (e.g., persistent
  depression after adequate duration of
  antidepressant trial)
• - Side effects
• Facilitate patient-provider (e.g., PCP)
  communication about antidepressant medications
• Consult with team psychiatrist about
• medication questions

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Using Antidepressants

• Key principles
• - Use antidepressants, not minor tranquilizers /
  benzodiazepines
• - Use adequate doses for an adequate amount of
  time
• - Start slow and work with side effects but
  titrate to an effective dose as needed
• Change medication if not effective
• Usually after 8-10 weeks

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FDA Approved Antidepressants

• Serotonin Reuptake Inhibitors (SSRIs)
• Fluoxetine (Prozac), paroxetine (Paxil),
  citalopram (Celexa), escitalopram (Lexapro),
  sertraline (Zoloft), fluvoxamine (Luvox)
• Newer Antidepressants (atypical)
• Buproprion SR (Wellbutrin), mirtazapine
  (Remeron), venlafaxine XR (Effexor), duloxetine
  (Cymbalta)
• Tricyclics (TCAs)
• Secondary amines nortriptyline, desipramine
• Tertiary amines imipramine, doxepin,
  amitriptyline
• not recommended for older adults

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Serotonin Reuptake Inhibitors (SSRIs)
Common side effects in all SSRIs (10 )
insomnia, restlessness, agitation, fine tremor,
GI distress (nausea, diarrhea) , headache,
dizziness, sexual dysfunction. mg
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Newer Antidepressants NSRIs
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Other Newer Antidepressants
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Secondary Amine Tricyclics (TCAs)
Common side effects in all TCAs (10 )
arrhythmias (particularly with preexisting
conduction defects), dry mouth, constipation,
blurry vision, orthostatic hypotension, and
weight gain. mg
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Choosing Antidepressants

• Prior treatment history in patient/family members
• Patient preferences
• Expertise of prescribing provider
• Side effect profile (sedating or activating)
• Safety in overdose (10 days of a TCA can be a
  lethal overdose)
• Availability and costs
• Drug-drug interactions

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Patient Education About Antidepressants

• Key messages
• - How do these medications work?
• By restoring a chemical imbalance in the brain
• - There are several options (over 20 available
  medications)
• Anticipate
• - Patient concerns about medications
• - Side effects (these can be managed)
• - Problems with adherence
• Reinforce
• - Need for continuation or maintenance treatment
  to prevent relapse even after the patient feels
  better

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Antidepressant Adherence

• Key messages
• Take medication daily
• Wait 2-4 weeks for effect
• Side effects can occur, but often resolve in 1-2
  weeks
• Keep taking medication even if better
• Check with MD before stopping
• Not addicting

Lin EH. Med Care 19953367
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Is the patient at maximum Therapeutic dose?

• Fluoxetine 60 mg
• Paroxetine 60 mg
• Escitalopram 30 mg
• Citalopram 60 mg
• Sertraline 200 mg
• Venlafaxine 300 mg
• Duloxetine 60 mg
• Buproprion SR 450 mg
• Mirtazapine 60 mg
• Nortriptyline 125 mg (check serum level)
• Despramine 200 mg (check serum level)

Consider titrating to these doses unless
patients do not tolerate these maximum doses
due to side effects.
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What about plan B?

• STAR-D Trial examined strategies for management
  of SSRI non-repsonders
• - about one in four patients who are changed to
  either another SSRI, Buproprion-SR, or
  Venlafaxine XR will respond to the new drug
• - 27 32 of patients will respond to
  augmentation with Buspirone or Buproprion

Rush et al, 2006 Trivedi et al, 2006
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Buproprion-SR, Sertraline or Venlafaxine- XR
after Failure of SSRIs for Depression
Rush et al. NEJM 2006
About one in four patients had a response after
switching to a new antidepressant with no
differential effect
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Medication Augmentation after the Failure of
SSRIs for Depression
Trivedi et al. NEJM 2006
No differences in response rates, but buproprion
was associated with greater reduction in
depressive symptoms and lower dropout from
side-effects than buspirone
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Common Side Effects

• Short term
• GI upset / nausea
• Jitteriness / restlessness / insomnia
• Sedation / fatigue
• Long term
• Sexual dysfunction

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Managing Side Effects

• Consult with prescribing provider / team
  psychiatrist
• Short term strategies
• - Wait and support (e.g., GI side effects)
• - Adjust medication timing (e.g., take sedating
  meds at bedtime)
• - Consider temporary dose reduction
• - Treat side effects (see intervention manual)
• Change to a different antidepressant
• Change to or add psychotherapy

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When and How to Stop Antidepressants?

• Risk of relapse
• - 50 if 1 prior episode
• - 75 if 2 prior episodes
• - 90 if 3 prior episodes
• - Also increased with dysthymia and residual
  depressive symptoms
• Treat all adults for 4-9 months after initial
  response.
• Treat those at high risk for relapse for 2 years
  or longer. Some may need lifetime treatment.
• Maintenance treatment should be at full dose.
• Make a relapse prevention plan.
• Taper antidepressants slowly to avoid
  discontinuation syndrome.

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Remember

• There are over 20 FDA approved antidepressants.
• - All are effective in 50 of patients
• - it may take several trials until an effective
  medication is identified for a particular
  patient
• - Patients need support during this time
• If medications are not effective after 8-10 weeks
  at a therapeutic dose
• - make sure patient is taking medication as
  prescribed
• - consult with prescribing provider
• - consult with team psychiatrist
• - a change in treatment plan is likely
  indicated
• (e.g., change in medication, augmentation of
  medication, switch to PST-PC or other
  depression treatment)