Depression- Treatment Regimens Flashcards
First-line MDD medications (just the drug classes)
SSRIs, SNRIs, bupropion, Trintellix, mirtazapine
When is psychotherapy considered?
Mild/moderate depression, but considered a key component for all patients
Response to MDD treatment
50% reduction in symptoms after 4 weeks
If an optimal response to MDD treatment occurs, what should you do next?
Have the patient continue on their medication at an optimal dose and re-evaluate them at 6, 8, and 12 weeks
What happens if symptoms persist after an adequate trial of MDD medication?
Switch to an alternate AD or augmenting the AD with an alternate MoA, SGA, or psychotherapy
Relationship between recurrence risk and depressive episodes
Recurrence increases and the number of episodes increases
How long should therapy go on for high-risk patients?
Potentially lifelong
What happens during weeks 1-4 of MDD treatment?
The medication BEGINS to work, full effects not experienced yet
Weeks 1-4: partial or no response
Assess adherence, increase dose if clinically tolerated and indicated. For severe symptoms, consider ECT
Weeks 1-4: full response
Maintain treatment if no issues with tolerability
What happens during weeks 4-8 of treatment?
Medication takes FULL effect
Weeks 4-8: partial or no response
Increase dose, change to alternate AD, try augmentation, or consider ECT (basically the same as weeks 1-4)
Weeks 4-8: full response
move to continuation phase
Acute phase timeline
~2-3 months
What happens during the acute phase?
Patient starts treatment based on preference or prior response, tolerability, side effects, potential DDIs, costs, and comorbid conditions
Goal of acute phase
REMISSION (NO SYMPTOMS!)
Continuation phase timeline
4-9 months
What happens during the continuation phase?
AD treatment should continue at the same dosage as required in the acute phase for another 4-9 months, usually in patients who are unlikely to relapse or have their first episode of MDD
Causes of relapse should be addressed (adherence, substance abuse, psychosocial pressure)
Goal of continuation phase
PREVENT RELAPSE OR RESIDUAL SYMPTOMS
Maintenance phase timeline
indefinite, lifelong
What happens during the maintenance phase?
For patients with chronic depressive symptoms or with a history of 3+ depressive episodes
Goal of maintenance
PREVENT RECURRENCE (another depressive episode)
What med should you avoid in patients with seizures?
Bupropion
What med should you avoid in patients with substance abuse?
Benzos
What med should you avoid in patients with cardiac complications?
TCAs
What med should you avoid in patients with GI bleeding and anticoagulation?
SSRIs
Special populations: elderly
Avoid bupropion if patient has seizures, but could be okay if the seizures are controlled
Avoid TCAs if patient has delirium
Avoid TCAs and SSRIs if patient has fall/fracture history
Elderly: best option for initial treatment
SSRI, but bupropion and venlafaxine are second options
Mirtazapine in elderly patients
Could be good in older, frail patients and have benefits in anxiety, sleep, and appetite stimulation
Special populations: peds
Therapy could be useful in mild depression
MDDs approved in peds
Fluoxetine for 8+, escitalopram in 12+
Special populations: pregnancy- what med should you avoid at all costs?
PAROXETINE
Pregnancy: medication approved for PPD
Brexanolone
Side effects of brexanolone
Suicidal thoughts and behavior, flushing, infusion site reactions
Brexanolone REMS program
On REMS because it can cause excessive sedation and loss of consciousness
MDD symptom resolution timeline: week 1
decreased anxiety, improved sleep and appetite
MDD symptoms resolution: weeks 1-3
increased activity, sex drive, self-care, memory, thinking and movements become more normal and so does sleeping and eating
MDD symptoms resolution: weeks 2-4
relief of depressed mood, thoughts of suicide begin to subside
What can be used to evaluate therapeutic outcomes?
Serum concentrations, side effects, remission of target symptoms, rating scales
BBW for all MDD meds
Increased risk of suicidality in young adults 18-24 years of age, especially at the early stage of treatment
The reasoning behind the BBW for MDD meds
Increased energy towards the beginning of treatment may help people go through with suicide plans/think of some
What to do about the BBW for MDD meds
Counsel patients/families to watch out for agitation, other symptoms at the beginning of treatment, provide resources for them (phone numbers, etc.), tell them that even though the BBW is for people ages 18-24, it could happen in anyone
