Medical Management of Depression - PowerPoint PPT Presentation

1 / 40
About This Presentation
Title:

Medical Management of Depression

Description:

Once a diagnosis has been made, effective management in primary ... Escitalopram (Lexapro) Fluoxetine (Prozac) Paroxetine (Paxil, Paxil CR) Setraline (Zoloft) ... – PowerPoint PPT presentation

Number of Views:330
Avg rating:3.0/5.0
Slides: 41
Provided by: nychealtha
Category:

less

Transcript and Presenter's Notes

Title: Medical Management of Depression


1
Medical Management of Depression
  • Public Health Detailers Training
  • NYC Department of Health and Mental Hygiene
  • Jorge R. Petit, MD
  • Associate Commissioner, Bureau of Program Services

2
Overview
  • Depression management
  • Types of antidepressants
  • Choosing an antidepressant
  • PCP concerns suicide risk, misdiagnosis of
    bipolar
  • PHQ9 as a monitoring tool
  • Treatment algorithm

3
Overview
  • Acute, Maintenance, Continuation Phases
  • Ongoing monitoring
  • Referral to Psychiatry
  • Involvement of non-physician staff

4
Depression Management
  • Once a diagnosis has been made, effective
    management in primary care includes
  • Medication management (Pharmacotherapy)
  • Patient education
  • Self management support
  • Ongoing monitoring, including monitoring of
    concurrent psychotherapy

5
Pharmacotherapy Types of Meds
  • Selective serotonin uptake inhibitors (SSRIs)
  • Other newer antidepressants (norepinephrine plays
    a key role)
  • Tricyclic antidepressants (not considered a
    first-line antidepressant)
  • MAO Inhibitors (rarely used by primary care
    physicians)

6
SSRIs
  • Citalopram (Celexa)
  • Escitalopram (Lexapro)
  • Fluoxetine (Prozac)
  • Paroxetine (Paxil, Paxil CR)
  • Setraline (Zoloft)
  • Duloxetine (Cymbalta)

7
SSRIs
  • Potential side effects
  • GI (N/V, diarrhea)
  • Activation/insomnia
  • Sexual Dysfunction
  • Neurological (headaches, etc)
  • Weight changes
  • Serotonin syndrome
  • Drug Interactions (MAOIs)

8
(No Transcript)
9
Dopamine-norepinephrine reuptake inhibitor
  • Buproprion (Wellbutrin SR, Wellbutrin XL)
  • Potential side effects
  • Neurological/seizures
  • Insomnia
  • GI upset
  • Psychotic symptoms

10
Norepinephrine serotonin neurotransmission
enhancer
  • Mirtazapine (Remeron)
  • Potential side effects
  • Sedation
  • Dry mouth
  • Weight gain
  • Increase serum cholesterol

11
Serotonin-norepinephrine reuptake inhibitor
  • Venlafaxine (Effexor XR)
  • Potential side effects
  • Similar side effect profile to SSRIs, including
    N/V, sexual dysfunction, and activation
  • Possible dose-related increase in BP

12
(No Transcript)
13
Tricyclics
  • As effective as newer agents
  • Side effects potentially more dangerous
  • dry mouth, constipation, bladder problems, sexual
    dysfunction, blurred vision, dizziness,
    drowsiness and increased heart rate.
  • Cheaper-especially generic forms
  • May be good for selected patients

14
(No Transcript)
15
Choosing an antidepressant
  • In general, no particular antidepressant is more
    effective than another
  • Choice should be based on
  • Family history of response
  • Safety and side effect profiles
  • Ease of use
  • Consider symptom profile/presence of
    comorbidities, ie. anxious, obsessive compulsive
  • cost

16
1st line antidepressants
  • All categories mentioned with the exception of
    trycyclics, MAOs
  • 1st line antidepressants have these factors in
    common
  • Once a day dosing (ease of use aids compliance)
  • Favorable side-effect profile (also aids
    compliance)
  • Safety in overdose
  • Broad efficacy for mood disorders

17
1st line antidepressants
  • Using these better tolerated, newer meds can
  • prevent the need for complicated
    titration-allowing for a quicker response
  • improve compliance
  • Lead to fewer office visits
  • Result in less overall cost

18
Suicide Risk
  • FDA Public Health Advisory March, 2004 possible
    risk of worsening depression and suicidality in
    patients taking antidepressants
  • Done in reaction to reports of suicidal ideation
    and attempts in treatment of major depression in
    pediatric patients.
  • Black box warning for children / adolescents
    September, 2004

19
FDA Public Health Advisory
  • Points out the need to closely monitor patients
    receiving antidepressants for worsening and
    suicidality especially at beginning of treatment
    and with changes in dosage
  • Also need to instruct patients and families to be
    alert for worsening or suicidal thoughts and to
    immediately report such symptoms

20
Misdiagnosis of Bipolar Patients
  • Potential risks from antidepressants
  • May induce mania or hypomania
  • Can cause rapid cycling
  • Requires mood stabilizer (e.g. lithium or
    valproic acid) before brief use of antidepressant
  • Generally need psychiatry consultation or referral

21
PHQ-9 as a monitoring tool
  • Quantifies the severity of depression (gives a
    number)
  • Provides measurement over the time which aids in
    assessing effectiveness of chosen treatment
    course
  • Follow-up PHQ9s should be conducted every month
    in person or over the phone

22
Remission
  • Goal of treatment full remission (absence of
    symptoms)
  • Monitoring with the PHQ9 can assist in the
    process of achieving full remission
  • A score of 5 or less on the PHQ9 full remission
  • Once remission is achieved, patient should remain
    on the current dose of medication for 6-9 months
    to prevent relapse

23
Treatment Algorithm
  • Decision support tool PCPs can use to manage
    depression
  • Assists with monitoring of medication and
    psychotherapy over all phases of treatment
  • Provides timeframes for effective monitoring
  • Pocket size version available

24
(No Transcript)
25
Phases of Treatment
  • Acute
  • Continuation
  • Maintenance

26
Acute Phase
  • Usually 6-12 weeks
  • Effective treatment response is usually obtained
    in this phase--initial remission

27
Continuation Phase
  • Usually 6-9 months
  • Residual symptoms can continue to impair patients
    and complicate co-morbid medical illness
  • Patients are prone to relapse during this phase
  • Important to continue full therapeutic dose
    during this phase

28
Maintenance Phase
  • 9 months
  • If 1st episode, meds should be tapered and
    discontinued
  • If recurrent episode, long term maintenance
    should be considered, generally at the
    therapeutic dose established in acute phase

29
Maintenance Phase
  • Other factors that would extend a course of
    antidepressant treatment include
  • patient preference
  • illness severity and related disability when
    affected

30
Ongoing Monitoring
  • Important for practices to have some sort of
    system in place for monitoring
  • Close follow up by telephone and or visits until
    stable
  • Severity tool (PHQ-9) to assess progress
  • Titrate dose for total remission

31
Ongoing Monitoring
  • Maintain effective dose for 4 to 9 months
    (continuation phase)
  • Monitor for early signs of recurrence
  • Consider maintenance therapy

32
Consider referral to psychiatrist if
  • PHQ9 20
  • Fails 1-2 medication trials
  • Is Suicidal
  • Exhibits psychotic or bipolar depression
  • Comorbid substance, physical, or sexual abuse
  • Severe psychosocial problems

33
Consider referral to psychiatrist if
  • Requires specialized treatment (MAO inhibitors,
    ECT)
  • Deteriorates quickly
  • Has unclear diagnosis

34
To Locate a Psychiatrist
  • American Psychiatric Association Answer Center
  • apa_at_psych.org or (888) 35-PSYCH
  • LIFENET (accessible 24/7)
  • 1-800-LIFENET (800-543-3638) or call 311 and ask
    for LIFENET

35
Patient Education
  • Key to promoting compliance with the treatment
    plan, patient becomes partner in care
  • Dispels negative perceptions/addresses stigma
    that may contribute to non-adherence
  • If patients know what to expect will be less
    likely to discontinue meds prematurely

36
Patient Education
  • Compare depression to other treatable medical
    illnesses to help patients feel less stigmatized
  • Inform patients that antidepressant medication
    helps correct imbalances in brain chemicals
  • Educate about medication options
  • Effectiveness, onset of action, potential adverse
    side effects
  • All patients should be cautioned not to expect
    immediate symptom relief
  • may need to take antidepressants for as long as 6
    weeks before they experience benefits

37
Key Educational Messages
  • For patients starting antidepressant meds
  • Antidepressants only work if taken every day
  • Antidepressants are not addictive
  • Benefits from meds appear slowly
  • Continue meds even after you feel better

38
Key Educational Messages
  • For patients starting antidepressant meds, cont
  • Mild side effects are common and usually improve
    with time
  • Some medications must be stopped gradually.
    Always consult a doctor before changing,
    reducing, or stopping a drug regimen.
  • The goal of treatment is complete remission
    sometimes it takes a few tries.

39
Use of Non-physician and Support Staff
  • Many of the monitoring and education functions
    important in the care of depressed patients can
    be handled by support staff, including
  • Administration/scoring of PHQ to monitor symptoms
  • Providing educational materials
  • Explaining care plan, what to expect, side
    effects

40
Use of Non-physician and Support Staff
  • Scheduling follow-up visits
  • Assisting with referral process
  • Care management
  • active patient follow-up through regularly
    scheduled phone contacts or visits
Write a Comment
User Comments (0)
About PowerShow.com