Major depressive disorder therapeutics

Depression rating scales

PHQ-9, Beck dep. inventory (BDI), Montgomery-Asberg dep rating scale (MADRS)

PHQ-9

9 questions rated 0 to 3

moderate: 10-14, severe 20-27

PHQ-9 question 9

Thoughts you would be better off dead or hurting yourself in anyway

PHQ-9 question 9 action when

If positive at all

PHQ-9 medication when?

If score 15-19 or 20-27

Moderately severe PHQ-9 tx

medication and/or therapy

Severe PHQ-9 tx

medication

MDD diagnosis

>5 sx over 2 wk period

Must include dep. mood or anhedonia

MDD sx

mood, sleep change, interests, guilt, decr energy, appetite change, suicidal ideation

Acute tx phase

6-12 weeks

Goal: remission

Continuation tx phase

4-9 months after remission

Goal: prevent relapse

Maintenance tx phase

12-36 months

Goal: prevent recurrence

non-pharm tx

CBT, ECT magnetic stimulation (rTMS), physical activity

Physical improvement

1-2 weeks

Psychological sx improvement

4-6 weeks

Remission

6-12 weeks

most antidepressants have this BBW

Incr risk of suicidal thoughts

citalopram (Celexa) dosing

initial 10-20 mg

max 40 mg

citalopram (Celexa) titration

double weekly

Escitalopram dosing

initial 5-10

Max 20 mg

fluoxetine (Prozac) dosing

10-20

max 80

escitalopram titration

increase to max after 1 week

fluoxetine (Prozac) titration

increase in 20 mg increments

fluoxetine (Sarafem) dosing

90 mg/week

fluvoxamine IR/ER dosing

initial 10-20

Max 300

paroxetine (Paxil) IR/CR dosing

initial 10-20

Max IR 50, CR 62.5

paraoxetine (Paxil) titration

IR 10 mg/day weekly

CR 12.5 mg/day weekly

sertraline (Zoloft) dosing

initial 25-50

max 200

sertraline (Zoloft) titration

25 mg/day weekly

SSRI generic contraindications

MAOi, linezolid, IV methylene blue, pimozide

Fluoxetine/paroxetine Ci

use with thioridazine

sertraline solution Ci

disulfiram

SSRI warnings

SIADH/hyponatremia, bleeding, beer's criteria

citalopram warning

QT prolongation

doses > 40 mg aren't recommended

Life threatening serotonin syndr sx

delirium, HTN, hyperthermia, muscle rigidity, tachycardia

sertraline ADE

Gi issues

fluoxetine ADE

activating

paroxetine ADE

sedating, wt gain

sertraline preferred in __ risk

cardiac

Drugs that increase bleed risk

Anticoag, NSAIDs, ginkgo, garlic, ginger, ginseng, glucosamine

CYP2D6 inhibitors

fluoxetine/paroxetine: avoid use with tamoxifen

SNRI drugs

pristiq, effexor, cymbalta, fetzima

Desvenlafaxine (Pristiq) dosing

initial: 50

max: 100 mg

desvenlafaxine titration

20 mg increments

duloxetine (Cymbalta) dosing

initial 30

max 120 mg

levomilnacipran (Fetzima) dosing

initial 20

max 120

levomilnacipran (Fetzima) titration

increase >equal 2 days

venlafaxine (Effexor) dosing

initial 37.5-75 mg

max ER 225, IR 375

venlafaxine (Effexor) titration

increase by 75 mg every 4 days

SNRI warnings

SIADH/hyponatremia, bleeding, beer's criteria

SNRI generic ADEs

dry mouth, constipation, excessive sweating, incr HR/BP, RLS, osteoporosis, dilated pupils

SNRI dilated pupil ADE leads to ___

narrow angle glaucoma

venlafaxine (Effexor) ADE

BP risk over 150 mg/day

desvenlafaxine (Pristiq) ADE

hyperlipidemia

duloxetine ADE

liver toxicity

venlafaxine (Effexor) DDI

additive QT prolongation

duloxetine DDI

w/ CYP2D6 inhibs

avoid use with tamoxifen

Mixed 5-HT drugs

vilazodone, trazodone, nefazodone

vortioxetine, mirtazapine

Vilazodone (Viibryd) dosing

10 mg x 7 days then incr to 20 mg daily

max 40 mg/day

vilazodone (Viibryd) pearls

Take with food

Comes in starter pack

vilazodone (Viibryd) warnings and Ci

Mania/hypomania, seizures

Ci use of MAOs within 14 days

trazodone (Desyrel) dosing

start 50 mg daily

max 600 mg/day

Hepatic adj

trazodone (Desyrel) warnings and Ci

CNS dep, falls, seizure disorder

ci: MAOIs within 14 days

trazodone (Desyrel) ADEs

priapism, orthostatic hypotension, cardiac arrythmias, withdrawal syndrome (insomnia)

nefazodone (Serzone) dosing

100 mg daily up to 600 mg/day

Should be divided twice daily

trazodone (Desyrel) BBW

hepatotoxicity

vortioxetine (Trintellix) dosing

5-20 mg/day w/ or w/o food

Decrease dose 50% when used w/ CYP2D6 inhibs

mirtazapine (Remeron) dosing

start 15 mg/day and titrate to max 45 mg/day

mirtazapine (Remeron) considerations

Renal dose adj for eGFR < 30

hepatic adj

mirtazapine (Remeron) warnings

antichol, fractures, solTab (contains phenylalanine), tablets (contain lactose)

mirtazapine (Remeron) ADEs

sedation, incr appetite, dyslipidemia

Bupropion (Wellbutrin) IR dosing

75 mg titrated to max 450 mg/day

Bupropion (Wellbutrin) ER dosing

150 mg titrated to max 450 mg/day

Bupropion (Wellbutrin) SR dosing

75 mg titrated to max 400 mg/day

Bupropion (Wellbutrin) warning

Decr seizure threshold, wt loss, CVD disease

Bupropion (Wellbutrin) Ci

seizure risk conditions, MAOis, eating disorder hx

MAO inhibitor drugs

phenelzine (nardil), selegiline (Ensam), tranylacypromine (parnate), isocarboxazid (Marplan)

phenelzine (nardil) dosing

initial 15 mg

max 90

Incr by 15 mg every 1-3 wks

selegiline (Ensam) selective for MAO__

B

selegiline (Ensam) dosing

initial 6 mg

max 12 mg

selegiline (Ensam) pearls

transdermal only, rotate sites

Increase by 3 mg/day every 2 weeks

Tranylcypromine (parnate) dosing

initial 10 mg

max 60

Incr by 10 mg Q1-3 wks

isocarboxazid (Marplan) dosing

initial 10 mg

max 60 mg

MAOi warnings/ADEs

serot synd, seizure

HTN crisis: avoid tyramine containing foods, sympathomimetics

tyramine containing foods

cheese plate with meats and wine

sympathomimetic drugs

pseudoephedrine and amphetamine

MAOi, SSRI, and bupropion washouts are ___ days

14

SNRI general washout period

5-7 days

TCA drugs

amitriptyline, desipramine, doxepin, imipramine, nortiptyline

TCA dosing

start 25 mg daily max 300 mg

exception: nortriptyline's max is 150 mg

amitriptyline brand

Elavil

desipramine brand

Norpramin

Doxepin brand

Sinequan

imipramine brand

Tofranil

nortriptyline

Pamelor

TCA ADE

antimuscarinic: constipation, urinary retention, blurred vision

Overdose risk: quinidine-like conduction effects

Wt gain

2nd gen antipsychotics for augmentation

abilify and seroquel

aripiprazole dosing

initial 2 mg titrated to max 15 mg

seroquel dosing

initial 50 mg titrated to 300 mg

augmentation alternatives

buspar, lithium, triiodothyronine (Cytomel)