Depression2015SummaryPage

StephenD.SissonMD/InternalMedicineCurriculum
Part1:Diagnosticcriteriafordepression
A.Foratleasttwoweeksduration,thepatienthasoneortwoof:
1. Depressedmood
2. Lossofinterestinnearlyallactivities(anhedonia)
B.ANDthreeorfourof(foratleastfivetotal):
1. Feelingsofworthlessnessorexcessiveguilt
2. Insomnia/hypersomnia
3. Fatigueorlossofenergy
4. Decreasedabilitytothinkorconcentrate
5. Substantialchangeinweight(>5%)orappetite
6. Psychomotoragitationorretardation
7. Recurrentthoughtsofdeathorsuicide
Part2:Suiciderisk
A.Riskfactorsforsuicide
1. Pasthistoryofsuicidalbehavior;familyhistoryofcompletedsuicide
2. Coexistinganxietyorpanicdisorder
3. Age>65
4. Malegender
5. CaucasianorNativeAmerican
6. Livingalone
7. Coexistingseriousmedicalillness
B.Otherfactorsassociatedwithincreasedriskofsuicideincludesuicidalthoughtswithspecificplan,clearintentonattempting
suicideanddetailed,violentplanforsuicide
Part3:Treatment
A.Milddepressionmaybetreatedwithmedsorcounseling(orboth);moderate/severedepressionshouldbe
treatedwithbothmodalities.Assesssuicideriskregularlyduringtreatment.
B.Pharmacotherapy(noteriskofsuicidehighestinfirst9daysafterprescriptionofanantidepressant)
1. SSRIs:Allhavesimilarefficacy;GI/sexualsideeffectspredominate.Withdrawalwithabruptdiscontinuation;riskof
serotoninsyndromeincombinationwithotheragentsthataffectserotonin.
a. Fluoxetine:start20mgdaily;max.80mgdaily.LongesthalflifeofSSRIs
b. Sertraline:start50mgdaily;max.200mgdaily.Greatestriskofcausingdiarrhea.
c. Paroxetine:start20mgdaily;max.50mgdaily.Greatestriskofsexualsideeffects.
d. Citalopram:start20mgdaily;max.40mgdaily.QTprolongationindoses>40mgdaily.
e. Escitalopram:start10mgdaily;max.20mgdaily.
2. SNRIs:SimilarsideeffectstoSSRIs,withfewerGIeffectsbutriskofhypertension.Theseagentsmostlikelyto
causediscontinuationduetosideeffects.
a. Venlafaxine:start27.5mgbid;maxdailydose375mg.
b. Duloxetine:start40mgdaily;max60mgdaily.
c. Desvenlafaxine:Doseat50mgdaily.
3. Otheragents
a. Trazodone:sedating.Start50mgtid;maxdailydose600mg
b. Bupropion:welltoleratedcomplementtoSSRIs.Seizureriskatstart.Start100mgbid,then100mgtid,or
delayedreleasestart150mgdailyx3daysthen150mgbidor300mgdaily.Fewestsexualsideeffects.
c. Mirtazapine:sedating;rareriskofagranulocytosis.Start15mgqhs;max.45mg.Mayhavemostrapid
onsetofaction.
4. Tricyclics:Nowconsideredsecondlineduetosuicideriskandsideeffects.Avoidinelderly,heartdisease,
intoleranceofanticholinergicsideeffects
a. Amitriptyline:start50mgqhs;max.300mg.Highlysedating/anticholinergic
b. Nortriptyline:start25mgtid/qid;max.150mgtotaldaily.Feweranticholinergiceffects
c. Desipramine:start75mgdailyordivideddose;max.300mgdaily.FATALwithoverdose
Part4:Assessingresponse
A. Earlyevidenceofresponsemaybeseenin34weeks;tominimizesideeffects,startatlowdose,assessfrequentlyand
advancedoseastoleratedoruntilsideeffectslimit.
B. Ifnoresponseat68wks,medicationmustbeswitched.
C. Ifpartialresponseat68wks,mayincreasedose,changemed,addcounseling,oraugmentwithanotheragent,suchas
bupropion,mirtazapine,lithium,triiodothyronineorrisperidone.
D. Continuetreatmentforatleast4monthsofclinicalresponse;ifdepressionrelapses,longertreatmentneeded.
Part5:Discontinuingtherapy
A. Continuetreatmentafterresponsefor69months.Remissiondefinedas3weekswithoutdepressedmoodandresolutionof
anhedonia,aswellasnomorethan3remainingsymptomsofdepressiveepisode.
B. Tapermedicationsslowly,over1month,andmonitorforevidenceofrelapse.Increasedosetoeffectivedoseifrelapse
evident.
C. Riskofrelapsehighwithmoreresidualsymptoms,priordepression,ongoingpsychosocialstressors