Depression Medical Management

Aka: Depression Medical Management, Medical Management of Depression

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II. Indications

  1. Moderate to Severe Major Depression
  2. Consider in Mild Major Depression

III. Approach

  1. Combine Antidepressants with Psychotherapy for Depression
  2. Providers tend to under dose depression
    1. Refractory Depression may simply need higher levels
  3. Duration of therapy after remission of symptoms
    1. Young: 6 months minimum treatment
    2. Elderly: 2 years minimum use
    3. Rebound Depression off medication: Indefinite use
      1. Continued use reduces relapse risk by two thirds
      2. Geddes (2003) Lancet 361:653-61 [PubMed]
  4. Specific Population Approaches
    1. See Pediatric Depression
    2. See Antepartum Depression
    3. See Depression in Athletes
    4. See Depression in Older Adults
    5. See Postpartum Major Depression

IV. Efficacy

  1. Antidepressants offer Statistically SignificantMajor Depression improvement, but not all patients benefit
  2. Fewer than one third of patients achieve Major Depression remission with the first Antidepressant
  3. Number Needed to Treat (NNT) to result in clinical response or remission
    1. Tricyclic Antidepressants NNT 9
    2. Selective Serotonin Reuptake Inhibitors (SSRI) NNT 7
    3. Venlafaxine NNT 6
  4. References
    1. Arroll (2016) J Prim Health Care 8(4): 325-34 [PubMed]
    2. Cipriani (2016) Lancet 391(10128): 1357-66 [PubMed]

V. Adverse Effects

  1. See Antidepressant Adverse Effects
  2. See Serotonin Syndrome
  3. See Antidepressant Withdrawal
  4. See Antidepressant Induced Sexual Dysfunction

VI. Protocol

  1. Choosing an Antidepressant
    1. Consider Antidepressant Adverse Effects
    2. Consider Antidepressants that have been effective for close family members
    3. Consider Depression Types (see below)
      1. Anxious or agitated
      2. Inhibited or withdrawn
    4. Start with generic agents if possible
  2. Warn patients about expected side effects
    1. See Antidepressant Adverse Effects
    2. At least 60% of patients will have some adverse effects, and these effects precede the benefit by months
    3. Consider effect on sexual function (see below)
  3. Choosing a dosage
    1. Many patients are not on the optimal dose
      1. Write prescription to allow patient to increase
    2. Start at sub-therapeutic dose to reduce side effects
    3. Increase dose to minimum effective dose in 5-7 days
    4. Allow patient to increase dose again in 2-3 weeks
    5. Example: Celexa 20 mg (write for 60 with refills)
      1. Start at 1/2 tablet daily for 5-7 days
      2. Then increase to 1 pill daily for 2-3 weeks
      3. Then consider increase to 2 pills daily
  4. Titrating to effective dose
    1. Increase dose as tolerated to optimal dose over 6 to 12 weeks
    2. Reevaluate at 4 to 6 weeks of optimal dose
      1. Consider adding a second agent if inadequate effect
      2. Consider switching agents if no significant improvement
  5. Antidepressant Course
    1. Acute Phase (6 weeks to 3 months)
      1. Target remission of symptoms and improved function
    2. Continuation Phase (4 to 9 months)
      1. Reduce relapse rates and keep symptoms at bay
      2. Continuation for at least 6 months is recommended
    3. Maintenance Phase (10 months to >1 year)
      1. Reduce risk of symptom recurrence
      2. Continue reevaluation of Major Depression
      3. Consider discontinuation as risk of recurrence decreases
  6. Switching Antidepressants
    1. Balance the risk of Serotonin Syndrome with the risk of Antidepressant Withdrawal
      1. Risk of Serotonin Syndrome if multiple Serotonergic Medications are used at the same time
      2. Risk of Antidepressant Withdrawal during a gap between Antidepressants
    2. Cross Taper
      1. Slowly decrease one medication dose by 25% of maintenance dose every 4 weeks AND
      2. Simultaneously start and titrate the new medication dose by 25% of target dose every 4 weeks
    3. Direct switch
      1. Stop one medication (consider tapering dose by 25% every 4 weeks before stopping)
      2. Washout period or gap between medications
        1. Choose either no gap between medications, a short gap of 2-3 days or a longer gap of 7 days
        2. Consider longer washout periods (4-5 half-lives) with longer Half-Life medications
      3. Start the new medication and titrate dose slowly to target dose
  7. Antidepressant Discontinuation
    1. Antidepressant is recommended for at least 6 months before stopping
    2. Risk of Antidepressant Withdrawal on stopping medication
      1. See Antidepressant Discontinuation Syndrome
    3. Decrease dose by 25% every 4 weeks or 12.5% every 2 weeks (stopping medication over 3-4 months)
      1. Citalopram 40 mg for 4 weeks, then 30 mg for 4 weeks, then 20 mg for 4 weeks, then 10 mg for 4 weeks...
    4. Review risk of relapse after medication discontinuation with patient
      1. Consider scheduled follow-up at 6-12 months after stopping medication
      2. Major Depression relapse occurrs within 1 year in >50% of patients after stopping meds after initial resolution
        1. Lewis (2021) N Engl J Med 385(14): 1257-67 [PubMed]

VII. Management: General agents

  1. First choice
    1. Escitalopram (Lexapro) or Citalopram (Celexa)
    2. Sertraline (Zoloft)
    3. Buproprion (Wellbutrin)
      1. Activating (consider in Fatigue, use caution in anxiety)
  2. Second choice (due to side effects)
    1. Fluoxetine (Prozac): Activating
    2. Paroxetine (Paxil): Sedating and withdrawal risk
    3. Mirtazapine (Remeron): Sedating and weight gain
      1. Elderly may see side effects as helpful
      2. May be helpful in Insomnia
  3. References
    1. Goad (2007) Chronic Disease Lecture, MPLS

VIII. Management: Agitation or Insomnia

  1. Use Sedating Antidepressant
    1. Paroxetine (Paxil)
    2. Mirtazapine (Remeron)
      1. Also useful in stimulating appetite, but risk of increased weight gain
  2. Consider medication to assist sleep
    1. Trazodone (Desyrel) 25-50 mg PO qhs
  3. Consider Benzodiazepine for first 1-2 weeks (Exercise caution)
    1. Clonazepam

IX. Management: Anxiety

  1. Paroxetine (Paxil)
  2. Venlafaxine (Effexor)

X. Management: Pain

  1. Duloxetine (Cymbalta)
  2. Venlafaxine (Effexor)
  3. Tricyclic Antidepressant

XI. Management: Psychotic Depression

  1. See Depression with Psychotic Features Management

XII. Management: Inhibited Depression

  1. First Line: SSRI
    1. Fluoxetine (Prozac)
    2. Bupropion (Wellbutrin)
  2. Second Line: Tricyclic Antidepressant
    1. Imipramine (Tofranil)
    2. Desipramine (Norpramin)
    3. Protriptyline (Vivactil)

XIII. Management: Sexual Dysfunction

  1. See Antidepressant Induced Sexual Dysfunction
  2. Man with Premature Ejaculation: Paxil
  3. Woman lacks orgasm: Buspar 30 minutes prior to sex
  4. Agents least likely to affect sexual function
    1. Nefazodone (Serzone)
    2. Bupropion (Wellbutrin)
    3. Mirtazapine (Remeron)
    4. Citalopram (Celexa)
    5. Fluvoxamine (Luvox)

XIV. Management: Perimenopausal Major Depression

  1. Estrogen Replacement effective as Antidepressant
    1. Soares (2001) Arch Gen Psychiatry 58:529-34 [PubMed]

XV. Management: Depression Refractory to Antidepressants

  1. See Refractory Depression Management

XVI. References

  1. (2022) Presc Lett 29(7): 37
  2. (2023) Presc Lett 30(5): 27-8
  3. Ables (2003) Am Fam Physician 67(3):547-4 [PubMed]
  4. Bridges (1995) Br J Hosp Med 54:501-6 [PubMed]
  5. Cadieux (1998) Am Fam Physician 58(9):2059-62 [PubMed]
  6. Kovich (2023) Am Fam Physician 107(2): 173-81 [PubMed]
  7. Little (2009) Am Fam Physician 80(2):167-72 [PubMed]
  8. Ruhe (2006) J Clin Psychiatry 67:1836-1855 [PubMed]
  9. Rupke (2006) Am Fam Physician 73(1):83-86 [PubMed]

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