Depression PART 2 _ 5 questions

initiation and next steps

1-2 week of antidepressant

• improved sleep and appetite

• SIDE EFFECTS appears

4-6 weeks of antidepressant

• initial improvements - physical and cognitive symptom improve first

• increase activity, sex drive, self-care, memory

• thinking/improvements and sleeping/eating patterns normalize

• SIDE effects minimize

6-8 weeks of antidepressants

• relief of depressed MOOD

• LESS hopeless/helpless

• thought of suicide subside! 진정되다

12+ weeks of antiderpesant

• SHOWS the MAX BENEFITS!!!

3 phases of depression treatment and monitoring

ACUTE treatment → CONTINUATION treatment → MAINTENANCE treatment

3 phases - ACUTE treatment

1-2 weeks: adverse effects, suicidal thoughts or behaviors, ADHERENCE

4-6 weeks: TREATMENT RESPONSE (PHQ-9), TOLERABILITY of adverse effects, suicidal thoughts or behaviors, adherence [check EFFICACY]

8-12 weeks: REMISSION 차도 or additional treatment response, adherence

3 phases - CONTINUATION treatment - up to 1 year

• PREVENT RELAPSE → stopping before 6 months increases relapse risk

• recommended for everyone

• monitor every 4-12 weeks

3 phases - MAINTENANCE treatment - BEYOND 1 YEAR

• PREVENT RECURRENCE (new episode)

• recommended for those at higher risk

  (childhood maltreatment(ACEs), early age of onset, history of > depressive episodes, persist or residual 잔류 depression symptoms, history of severe or complicated depression or anxiety, current psychosocial stressors or impairment)

• monitor every 3-12 months

Relapse VS Recurrence

relapse is thought to be a return of symptoms of an ongoing episode that was symptomatically suppressed

recurrence represents an entirely new episode

Treatment selection - selection based on patient and treatment specific facors

• expected efficacy

• expected acceptability, tolerability, safety

• patient preference and treatment goals

Additional antidepressant indications

• smoking cessation - bupropion

• migraine - venlafaxine, amitriptyline

• anxiety - SSRIs, SNRIs

• ADHD - bupropion, TCAs

• insomnia - mirtazapine, trazadone, TCAs

• neuropathic pain - TCAs, duloxetine

GOAL of antidepressant treatment

• REMISSION 차도

Alternative PERSON-CENTERED GOAL

• symptom reduction to levels acceptable to the patient

• support broader domains of life satisfaction and well-being (functioning, QOL, coping abilities, stress tolerance, mental health outlook)

• maintain antidepressant tolerability, acceptability and access

• achieve patient’s goals of treatment

Goal of antidepressant dosing is to identify

LOWEST EFFECTIVE DOSE

Starting doses are generally low to

MINIMIZE SIDE EFFECT BURDEN

4-6 week follow-up: next steps in depression medication management

Is patient experiencing satisfactory response? → if YES

continue out to 1 year with appropriate f/u, then re-evaluate need for continued maintenance treatment

4-6 week follow-up: next steps in depression medication management

Is patient experiencing satisfactory response? → if NO

• non-adherence occurring?

• subtherapeutic dose? (약·비타민 따위를 치료 효과를 위해) 필요량 이하로 처방하는

• unaddressed psychosocial factors?

If staring dose is subtherapeutic,

INCREASE DOSE every 1-2 weeks as tolerated until therapeutic dose is reached!

[T/F]

Slow down titration if side effects persist, worsen or become bothersome.

TRUE

once dose within the therapeutic range is reached, allow [ ] weeks for response.

4-6

NON-adherence with antidepressants is common and associated with

INCREASED RISK FOR RELAPSE AND RECURRENCE OF DEPRESSION

IF patient experiencing NOT satisfactory response

→ and MINIMAL TO NO RESPONSE, then

STOP current antidepressant, START new agent (SWITCH)

*Re-assess response 2-4 weeks

Educate patient NOT to abruptly stop antidepressants, due to the risk of

DISCONTINUATION SYMPTOMS

→ TAPER dose over 2-3 weeks

Half-life and discontinuation risk

SHORTER half-life: GREATER WITHDRAWAL RISK with missed doses or discontinuation, requires SLOWER, MORE GRADUAL TAPER

longer half-life: less impact from missed doses, lower risk of discontinuation symptoms, better choice for people with adherence problems

Shorter half-life drugs

SSRIs - Fluvoxamine (15hours), Paroxetine (21 hours)

SNRIs (~12 hours, varies by agent)

Longer half-life drugs

SSRIs - Fluoxetine (4-6days)

Others - Vortioxetine (2-3days)

Switching antidepressants

within-class switch and across class switch are EQUALLY EFFECTIVE strategies.

Cross-taper approach VS Direct switch approach

Cross-taper approach = usually ACROSS CLASS switch (out of class switches)

: slowly decrease of initial antidepressant + slowly increase of new antidepressant

(ex. SSRI → SNRI)

Direct switch approach = usually WITHIN CLASS SWITCH

: switch DIRECTLY to equivalent dose (ex. SSRI → SSRI)

IF patient experiencing NOT satisfactory response

→ and SOME RESPONSE, then

ADD on 2nd medication (combination or augmentation 증가 therapy)

*RE-assess response 2-4 weeks

KEY of antidepressant combination

COMBINE antidepressant with DIFFERENT MOAs to involve additional neurotransmitters and/or pathways. NEVER use to antidepressants from the SAME class.

Antidepressant combinations EXs

SSRI + mirtazapine OR bupropion

SNRI + mirtazapine OR bupropion

Mirtazapine + bupropion

Trazodone or low dose TCA added at bedtime for sleep

*Combination of reuptake inhibitor + mirtazapine may be particularly effective!

WARNING of using antidepressant combinations

AWALYS AVOID combination of MAOI with ANY OTHER ANTIDEPRESSANTS!!!

AVOID combinations of antidepressants with SIMILAR MOA.

Ketamine, esketamine (Spravato™)

• Augmenting agents - NMDA receptor antagonists

• Ketamine = non-FDA approved / Esketamine = FDA approved

• Time to benefit = 1-2 days → quickly reduce suicidal symptoms, thoughts and behavior

Dextromethorphan HBr-Bupropion HCl (Auvelity)

• Augmenting agent - combo of a NMDA receptor antagonist (dextromethorphan) and NDRI (bupropion

• Time to benefit 1-2 weeks → slower than ketamine, esketamine