Depress
Depression Medical Management
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Depression Medical Management
, Medical Management of Depression
See Also
Refractory Depression Management
Depression Management Special Circumstances
General
Providers tend to under dose depression
Refractory Depression may simply need higher levels
Duration of therapy after remission of symptoms
Young: 6 months minimum treatment
Elderly: 2 years minimum use
Rebound Depression off medication: Indefinite use
Continued use reduces relapse risk by two thirds
Geddes (2003) Lancet 361:653-61 [PubMed]
Protocol
Choosing an
Antidepressant
Consider
Antidepressant Adverse Effects
Consider Depression Types (see below)
Anxious or agitated
Inhibited or withdrawn
Consider effect on sexual function (see below)
Start with generic agents if possible
Choosing a dosage
Many patients are not on the optimal dose
Write prescription to allow patient to increase
Start at sub-therapeutic dose to reduce side effects
Increase dose to minimum effective dose in 5-7 days
Allow patient to increase dose again in 2-3 weeks
Example:
Celexa
20 mg (write for 60 with refills)
Start at 1/2 tablet daily for 5-7 days
Then increase to 1 pill daily for 2-3 weeks
Then consider increase to 2 pills daily
Management
Gene
ral agents
First choice
Citalopram
(
Celexa
)
Sertraline
(
Zoloft
)
Buproprion (
Wellbutrin
)
Second choice (due to side effects)
Fluoxetine
(
Prozac
): Activating
Paroxetine
(
Paxil
): Sedating and withdrawal risk
Mirtazapine
(
Remeron
): Sedating and weight gain
Elderly may see side effects as helpful
References
Goad (2007) Chronic Disease Lecture, MPLS
Management
Agitation
or
Insomnia
Use Sedating
Antidepressant
Paroxetine
(
Paxil
)
Mirtazapine
(
Remeron
)
Consider medication to assist sleep
Trazodone
(
Desyrel
) 25-50 mg PO qhs
Consider
Benzodiazepine
for first 1-2 weeks
Clonazepam
Management
Anxiety
Paroxetine
(
Paxil
)
Venlafaxine
(
Effexor
)
Management
Pain
Duloxetine
(
Cymbalta
)
Venlafaxine
(
Effexor
)
Tricyclic Antidepressant
Management
Psychotic Depression
See
Depression with Psychotic Features Management
Management
Inhibited Depression
First Line:
SSRI
Fluoxetine
(
Prozac
)
Bupropion
(
Wellbutrin
)
Second Line:
Tricyclic Antidepressant
Imipramine
(
Tofranil
)
Desipramine
(
Norpramin
)
Protriptyline (Vivactil)
Management
Sexual Dysfunction
See
Antidepressant Induced Sexual Dysfunction
Man with Premature Ejaculation:
Paxil
Woman lacks orgasm:
Buspar
30 minutes prior to sex
Agents least likely to affect sexual function
Nefazodone
(
Serzone
)
Bupropion
(
Wellbutrin
)
Mirtazapine
(
Remeron
)
Citalopram
(
Celexa
)
Fluvoxamine
(
Luvox
)
Management
Perimenopausal
Major Depression
Estrogen Replacement
effective as
Antidepressant
Soares (2001) Arch Gen Psychiatry 58:529-34 [PubMed]
Management
Depression Refractory to
Antidepressant
s
See
Refractory Depression Management
References
Ables (2003) Am Fam Physician 67(3):547-4 [PubMed]
Bridges (1995) Br J Hosp Med 54:501-6 [PubMed]
Cadieux (1998) Am Fam Physician 58(9):2059-62 [PubMed]
Little (2009) Am Fam Physician 80(2):167-72 [PubMed]
Ruhe (2006) J Clin Psychiatry 67:1836-1855 [PubMed]
Rupke (2006) Am Fam Physician 73(1):83-86 [PubMed]
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