PSYC 5+6 MDD Therapeutics

Median time to recovery for MDD

20 weeks (5 months)

PHQ-9 Score for moderate-severe depression

15+

PHQ-9 Score moderate depression

10-14

When considering treatment for depression, what counts as elderly

65+

When is psychotherapy as effective as medications for depression

Mild-moderate depression

—> but psychotherapy + medication = always more effective than just medication alone

1) Duration of acute phase

2) Goal during acute phase

3) When does the acute phase “ideally end”

8-16 weeks

• Remission of symptoms

• Address patient safety

• Restore normal functioning

Ideally ends when symptom remission is achieved

Acute Phase Investigations:

1) What lab tests should be ordered

CBC

Serum chemistries

Thyroid panel

Out of the 1st line drugs, which were shown to have higher efficacy and lower dropout rates (4)

Escitalopram

Sertraline

Paroxetine

Mirtazapine

In the treatment algorithm:

1. When should you check for early improvement

2. What else should you do at this time

3. What counts as early improvement

1. 2-4 weeks

2. Target dose if rx needs to be titrated (venlafaxine, sertraline)

3. 20-30% reduction in symptoms from baseline

In the treatment algorithm:

After the initial 2-4 weeks, how much longer should you continue therapy before checking for symptom remission

6-8 weeks (10-12 weeks total)

In the treatment algorithm:

Once symptom remission occurs, how long should you continue the medication for? Are there any outliers?

9 months

—> 2 years in those at risk of reoccurence

—> If social stressor is gone, you can discontinue

Which drug is VERY stimulating, can cause anorexia, and has a long half life of 4-6 days

Fluoxetine (long half life like having the FLU)

Which drug is likely the most anticholinergic SSRI (drowsiness, constipation, dry mouth)

Paroxetine

Which antidepressant causes the most male sexual dysfunction + diarrhea

Sertraline

Which antidepressant causes the most drowziness

Trazodone

Is sexual dysfunction from depression / antidepressants reversible

Usually

Pharmacological strategies for sexual dysfunction

1) Augment with bupropion (add or switch to)

2) Mirtazapine

3) Sildenafil / Tadalafil

4) Transdermal testosterone

** Usually you wanna wait for spontaneous remission or dose reduction of current med if mood disorder is stable

** Also remember to rule out causes (alcohol/substance, cardiac disease, diabetes, etc)

Which antidepressants have a risk of cardiac arrhythmia

—> If these drugs must be used in high risk patient, what needs to be conducted + at what times (3)

Tricyclic Antidepressants (due to ion blockade)

• ECG at

  • Baseline

  • 1 week after each increase in dose

  • Periodically throughout treatment

Whats the duration of the maintenance phase

9-24 months or longer

How long do we need absence of symptoms to be considered remission

At least 2 months

When to consider SWITCHING antidepressant

1. It’s the first antidepressant trial

2. Intolerable side effects to initial antidepressant

3. Less urgent cases (pt willing to wait)

4. Patient prefers to swirch

5. No response <25% improvement initially

When to AUGMENT antidepressant therapy

1. Two or more ADEQUATE antidepressant trials

2. There is partial response to an antidepressant >25%

3. Specific side effects that can be targeted/fixed

4. Less time to wait for response (urgent)

5. Patient prefers to augment

When it comes to augmenting for antidepressants, what’s first line and what’s second line

First line = Aripiprazole / Brexpiprazole

Second line = Bupropion + Mirtazapine

—> CHOOSE 2ND LINE FIRST (Unless indicated for antipsychotic like mania)

**MIRTAZAPINE WORKS BEST!!

• Just beware of SE like weight gain, sedation, constipation, dry mouth

DISCONTINUATION SYNDROME

1) What is it/When does it happen

2) What does it look like

1) Can occur when you suddenly stop taking antidepressants or if the dose is tapered too quickly

2) FINISH symptoms

1. Flu like symptoms

2. Insomnia

3. Nausea

4. Irritability

5. Sensory changes (Tingling, shocks)

6. Headache

TAPERING
1) Generally, for most antidepressants, how long should you taper off of them

2) What 2 antidepressants do you need to SLOWLY taper due to short half lives (2)

3) What’s a wash out period

4) Is cross tapering often used

1) 2-6 weeks

2) Paroxetine + Venlafaxine

3) Waiting time after stopping one med before starting another med

4) Not really

Psilocybin

1) MOA

2) Promotes ___ expression of ___ (promoting plasticity)

3) Another possible MOA = possible ____ of ____ and ___

1. Agonizes 5-HT(2A) receptor (produces psychedelic effect)

2. Promotes downstream expression of BDNF (promotes plasticity)

3. Possible inhibition of SERT and NET

EXAMPLE CASE:

A depressed patient has been responding well to a medication. Recently, a family member died and now they’re super depressed!

(Bereavement is making already existing depression worse!)

1. What should you do (2)

2. What should you NOT do (1)

1) Augment medication or increase dose of current medication

2) DO NOT SWITCH (they were doing fine on it before bereavement)

1) Which antidepressant is associated with septal wall defects (pregnancy)

2) In pregnancy, when should you ALWAYS recommend antidepressant pharmacotherapy

3) What are the first-line antidepressants in pregnancy (3)

1) Paroxetine

2) If severe, (mod-severe), however, psychotherapy is first line!

3) First line in preg:

• Escitalopram

• Citalopram

• Sertraline

Postpartum : Lactation

1) 1st line

2) Which drugs can you use (same as pregnancy)

3) What drugs have lowest infant doses + milk-plasma ratio that can also be considered (3)

1) Psychotherapy

2) Escitalopram, citalopram, sertraline

3) Sertraline, Fluvoxamine, Paroxetine

1) Pediatric depression risk factors (5)

2) For 13-18 year olds, what can depression look like

1. Maternal age < 18 years old

2. Family history

3. Bullying

4. Parental or family conflict

5. Early trauma

2) 13-18 y/o symptoms:

• Decreased grades

• Poor school performance

• Refusal to attend school

• Eating disorders

• Self-Harm

Pediatric depression

1st line = psychotherapy

1) What’s the first line drug that is superior to placebo in this population

Fluoxetine

Elderly depression: Why are we worried if it’s a new onset (first onset) of MDD

Leads to worse prognosis, higher relapse rate, higher mortality

—> Screen for differential including prodromal dementia

Elderly:

1) Most important point of tapering onto medication

2) To switch vs augment

3) Preferred drug class

1) START LOW GO SLOW!

2) Switch (don’t want polypharmacy)

3) SSRIs/SNRIs (SSRI better bc no NE activitiy)