CANMAT guidelines

Question 1

CANMAT Guidelines for MDD 2009: Depression Pharmacotherapy

Answer 1

• First Line:
-SSRI: citalopram (20-60mg), escitalopram (10-20mg), fluoxetine (20-80mg), fluvoxamine (100-300mg), paroxetine (20-60mg), sertraline (50-200mg).
-SNRI: venlafaxine (75-375mg), desvenlafaxine (50-100mg), duloxetine (60-120mg).
-NDRI: bupropion (150-300mg)
NaSSA: mirtazapine (30-60mg)
MAOi (reversible): moclobemide (300-600mg)

• Second Line:

• TCA: eg. amitriptyline, clomipramine etc.
• atypical antipsychotic quetiapine (150-300mg), -serotonin reuptake inhibitor 5HT2 antagonist trazodone (150-300mg)

Question 2

CANMAT Guidelines for MDD 2009: Depression Pharmacotherapy for Non-Responders/Incomplete Responders

Answer 2

• First Line:
1. Switch to Rx with evidence of superiority – ie more positive RCTs (sertraline, escitalopram, duloxetine, venlafaxine, mirtazapine)
OR
2. Add another agent (aripiprazole, olanzapine, risperidone, lithium)

• Second Line:
1. Add-on another agent (bupropion, mirtazapine, quetiapine, T3, or other antidepressant)
OR
2. Switch to an agent with evidence of superiority but that has side effect limitations (amitriptyline, clomipramine, MAOi)

Question 3

CANMAT Guidelines for MDD 2009: Depression psychotherapy

Answer 3

• First Line: Cognitive Behavioural Therapy, Interpersonal Therapy
• Second Line: Bibliotherapy, Computer-Assisted CBT, Telephone Delivered CBT and IPT, Behavioural Activation, CBASP (Cognitive Behavioural Analysis System of Psychotherapy – esp for chronic MDD)

NOTE: Psychodynamic therapy is among 3rd line options by CANMAT Guidelines

Question 4

CANMAT Guidelines for Anxiety Disorders 2006

Answer 4

• These guidelines are divided into the separate anxiety disorders

• In summary:
first line: SSRI (sertraline, escitalopram, paroxetine, fluoxetine, fluvoxetine) or Effexor XR

**note: mirtazapine and bupropion, which are first-line for depression, are 2nd to 3rd line options in anxiety

Question 5

Antidepressants and the elderly

Answer 5

Antidepressants are metabolized by the liver and many have interactions with the CYP450 system. Those that are often used in the elderly are citalopram (CELEXA), escitalopram (CIPRALEX), sertraline (ZOLOFT), mirtazapine (REMERON). Note that the FDA warning for longQT and citalopram can be limiting in the elderly because they are not to take more than 20mg which is the usual lowest therapeutic dose. Start at half the usual starting doses (eg. citalopram 10mg, escitalopram 5mg, mirtazapine 7.5mg) and titrate slowly.

Question 6

Antidepressants and pregnancy/breastfeeding

Answer 6

Sertraline (ZOLOFT) seems to be the safest SSRI to be taking in pregnant or breastfeeding women.

Question 7

Antidepressants and breast cancer

Answer 7

Tamoxifen requires 2D6 activity to be activated. Paroxetine (PAXIL) and fluoxetine (PROZAC) are potent inhibitors of 2D6 and should not be given to patients taking tamoxifen.

Question 8

Sexual dysfunction from SSRIs

Answer 8

1) Trial decrease in dose (especially if they are on high dose and are stably remitted), 2) switch to a non-SSRI (eg. Mirtazapine, bupropion) –> note that neither mirtazapine or bupropion are first-line treatments for anxiety so this is less of a possibility for anxiety patients 3) Adding a PDE-5 inhibitor (ie. Sildenafil aka ‘Viagra’) may be useful for men