Antidepressant Deck 3 Flashcards
Treatment principles
Goals
Strategic and tactical decision making
patient counseling
Strategic and Tactical Decision-Making
Patient factors
Disease Factors
Drug Factors
Optimum Plan
“The whether and what”
You don’t want to treat to ____ you want to treat to __
response
remission
Initiation
Targeted Therapy
Dosing
Frequent Monitoring
Antidepressent most side effects are worse within
the first couple of weeks
Targeted therpay
y Patient factors
y Drug factors
y Disease Factors/Co-morbidities
Frequent Monitoring
y Weekly-biweekly
y Suicide risk
y Adverse effects
y Expected outcome/Effects
Titration: Med change every
3-14* days
you want to get to a
therapeutic dose
If no response and you are at a maximum dose at 8 to 12 weeks
y Change to different class or change to different med w/in same class if no response after 8-12 weeks of maximum dose
Oher options if you are at a maxium dose
add a second agent
refer to psych consultation
Follow up:
every 1-2 weeks for 6-8 weeks in initiation;
every 2 months for severe
Use _____ to monitor symptoms
clinical tools
Usual course of treatment
Major depression: 6-9 months*
Long term treatment may be needed
Common causes of treatment failure
y Inadequate dose or duration of treatment
y Prominent side effects
y Non-compliance
y Incorrect diagnosis
Plasma levels: when to use
y Failure to respond/use of higher than usual doses
y Impaired physical status
y S/E evaluation and/or overdose
Partial response: consider
augmentation
Factors to consider with augmentation
Efficacy, tolerability, side effect burden, drug interactions, dosing
convenience, adherence, cost
You want to add an agent from
Add agent from a different class y Wellbutrin, BuSpar (most commonly added)
Examples of other agents
y Anxiolytics y Antipsychotics and mood stabilizers y Psychostimulants y DHEA y Triiodothyronine (T3) y Ketamine?
What is not recommended due to interaction with SSRI
St. john’s wart - significant. Increases effects of SSRI
Withdraw medication
slowly. 2 to 4 week taper
Taper method
decreasing dose, then every other day, or a half a dose at a time. Depends on the indvidual
RCT: no difference in
no difference in symptoms between 3 day and 14 day
taper - anecdotally not Mary’s experience
Monitor what during withdrawl period
mood
review what during taper
relapse criteia
consider what during taper
seasonal and situational data
SSRI/SNRI disconintuation syndrome in adults acronym
FINISH
F
Flu like symptoms: fatigue, H/A, myalgias, diarrhea
I
Insomnia: vivid or disturbing dreams
N
Nausea
I
Imbalance: gait instability dizziness vertigo mbalance: gait instability, dizziness, vertigo
S
Sensory imbalance: paresthesia, “electric shock” sensation,
visual disturbances
H
Hyperarousal: anxiety, agitation
Onset and resolution of FINISH
Onset: 24-72h + resolution:1-14 days
Incidence of Finish
Incidence: 20-40% (treated at least 6wks)
Serotonin Syndrome S/S
y Signs and Symptoms y CNS and neuromuscular y Autonomic instability y GI: nausea, diarrhea y Onset: often rapid (minutes); may be life threatening
Serotonin Syndrome treatment
y Stop medication
y Benzodiazepines for agitation, hyperreflexia
y Treat individual symptoms (depends on severity)
