Pearls for prescribing Antidepressants and mood stabilizers - Zuchowski

Question 1

What is the best predictor for whether or not a person will respond well to a certain antidepressant?

Answer 1

Whether or not they have used it successfully before.

Question 2

If a person has a new onset depressive episode how do we know if it is major depressive disorder or if it is the first episode of a bipolar disorder?

Answer 2

There is no way to know for sure but we want to be careful prescribing antidepressants because they can actually trigger a manic episode. Things you should consider are:

1. if there was ever a personal history of mania
2. if there is a family history of mania
3. if the patient has 2 reverse vegetative signs
4. age of onset - unipolar depression can have a later onset like 40’s or later
5. if the patient has a history of multiple poor responses to antidepressants

Question 3

What are reverse vegetative signs?

Answer 3

Vegetative signs include changes in appetite and sleep. The typical changes in appetite and sleep - such as increased sleep and fatigue in depression may be opposite in bipolar. So if you are thinking depression but the patient has 2 opposite vegetative signs then it might be bipolar instead.

Question 4

What factors should be considered when choosing an antidepressant?

Answer 4

1. Personal and family history - ask about previous antidepressant use or use in family, ask about co-morbidities (ie. should not use wellbutrin if pt has bulimia because it increases risk for seizures), other meds and if there is any chance for pregnancy (would not want to use Paxil in a pt who is or may become pregnant)
2. Idiosyncratic - ask the patient what they have heard about the different antidepressants - their beliefs may affect how well they will do on an antidepressant
3. financial - what is affordable for the patient and does their insurance cover it

Question 5

Is one antidepressant more effective than the others?

Answer 5

No, evidence says that all antidepressants are equally effective, regardless of specific depressive symptoms.

Question 6

Even though all antidepressants are equally effective, what can differ among them?

Answer 6

The side effect profiles can differ and should be considered for each patient.

Question 7

What are some factors that should not be part of the decision about which antidepressant to use?

Answer 7

Prescriber centered factors such as:

1. prescriber favorites
2. primacy and recency effects - prescribers may tend to use what has worked well recently
3. impact of sales and marketing efforts

Question 8

What education should you provide when you prescribe an antidepressant?

Answer 8

1. how to take - i.e. time, with/without food etc.
2. take every day regardless if you feel good that day
3. may take 2-6 weeks for beneficial effect
4. estimate timeframe in which to be on the drug - should be a 6-9 month minimum
5. let them know there are other choices if this one doesn’t work
6. talk about the most common side effects, and the most extreme side effects
   Think about the reasonable patient standard - What would a reasonable patient want to know about the drug?

Question 9

What are the most common clinically significant side effects of the SSRI’s?

Answer 9

1. GI disturbance - especially nausea (25%)
2. sedation (20%)
3. restlessness/agitation (15%)
4. insomnia (15%)
5. decreased libido and/or delayed orgasm (15% but probably much higher)

Question 10

Describe some factors associated with initial monitoring and decision making about a switch in antidepressants.

Answer 10

1. schedule an initial recheck - do not tell the pt to just call if there are problems
2. how soon to switch depends upon severity of symptoms, reliability of the patient and comorbidities present
3. if there is zero benefit after 4 weeks then this is a predictor of poor ultimate response so offer to switch
4. if there is some benefit at 4 weeks - wait longer and consider dosage increase

Question 11

If treatment fails then what?

Answer 11

1. revisit diagnosis
2. check on adherence
3. consider co-morbidities like a medical condition or substance abuse
4. consider unaddressed situations that may be causing depression
5. consider augmentation such as psychotherapy
6. consider switching meds such as SSRI to SSRI, Bupropion to an SSRI or SSRI to an SNRI

Question 12

In summary, what are the most important things to think about when prescribing antidepressants?

Answer 12

1. know what you are diagnosing and treating
2. let severity of distress/dysfunction and duration of symptoms be your guide
3. most reliable predictor of future response is past response
4. statistically, all antidepressants are equally effective
5. wait 4-6 weeks before considering switch

Question 13

What sorts of things should be considered when managing mania?

Answer 13

1. consider whether hospitalization is needed to protect the safety, prevent financial ruin or ensure adherence
2. if on an antidepressant - stop the use
3. offer a mood stabilizer

Question 14

What is the gold standard for bipolar/mania treatment?

Answer 14

Lithium

Question 15

What are some commonly used mood stabilizers?

Answer 15

Sedating atypical antipsychotics such as:

1. risperidone
2. olanzapine
3. quetiapine

Question 16

What are some other options for treating mania/bipolar?

Answer 16

1. valproic acid

2. carbamazepine

Question 17

List some of the first line anti-manic meds.

Answer 17

1. lithium - is effective and has anti-suicidal effects but requires close monitoring due to its potential for toxicity
2. Valproic acid - safe and effective but may cause weight gain, is a teratogen and requires lab monitoring
3. atypical antipsychotics - fast-acting, well tolerated and easy to dose but may cause metabolic syndrome, weight gain and movement disorders