Depression- Treatment Regimens

Question 1

First-line MDD medications (just the drug classes)

Answer 1

SSRIs, SNRIs, bupropion, Trintellix, mirtazapine

Question 2

When is psychotherapy considered?

Answer 2

Mild/moderate depression, but considered a key component for all patients

Question 3

Response to MDD treatment

Answer 3

50% reduction in symptoms after 4 weeks

Question 4

If an optimal response to MDD treatment occurs, what should you do next?

Answer 4

Have the patient continue on their medication at an optimal dose and re-evaluate them at 6, 8, and 12 weeks

Question 5

What happens if symptoms persist after an adequate trial of MDD medication?

Answer 5

Switch to an alternate AD or augmenting the AD with an alternate MoA, SGA, or psychotherapy

Question 6

Relationship between recurrence risk and depressive episodes

Answer 6

Recurrence increases and the number of episodes increases

Question 7

How long should therapy go on for high-risk patients?

Answer 7

Potentially lifelong

Question 8

What happens during weeks 1-4 of MDD treatment?

Answer 8

The medication BEGINS to work, full effects not experienced yet

Question 9

Weeks 1-4: partial or no response

Answer 9

Assess adherence, increase dose if clinically tolerated and indicated. For severe symptoms, consider ECT

Question 10

Weeks 1-4: full response

Answer 10

Maintain treatment if no issues with tolerability

Question 11

What happens during weeks 4-8 of treatment?

Answer 11

Medication takes FULL effect

Question 12

Weeks 4-8: partial or no response

Answer 12

Increase dose, change to alternate AD, try augmentation, or consider ECT (basically the same as weeks 1-4)

Question 13

Weeks 4-8: full response

Answer 13

move to continuation phase

Question 14

Acute phase timeline

Answer 14

~2-3 months

Question 15

What happens during the acute phase?

Answer 15

Patient starts treatment based on preference or prior response, tolerability, side effects, potential DDIs, costs, and comorbid conditions

Question 16

Goal of acute phase

Answer 16

REMISSION (NO SYMPTOMS!)

Question 17

Continuation phase timeline

Answer 17

4-9 months

Question 18

What happens during the continuation phase?

Answer 18

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)

Question 19

Goal of continuation phase

Answer 19

PREVENT RELAPSE OR RESIDUAL SYMPTOMS

Question 20

Maintenance phase timeline

Answer 20

indefinite, lifelong

Question 21

What happens during the maintenance phase?

Answer 21

For patients with chronic depressive symptoms or with a history of 3+ depressive episodes

Question 22

Goal of maintenance

Answer 22

PREVENT RECURRENCE (another depressive episode)

Question 23

What med should you avoid in patients with seizures?

Answer 23

Bupropion

Question 24

What med should you avoid in patients with substance abuse?

Answer 24

Benzos

Question 25

What med should you avoid in patients with cardiac complications?

Answer 25

TCAs

Question 26

What med should you avoid in patients with GI bleeding and anticoagulation?

Answer 26

SSRIs

Question 27

Special populations: elderly

Answer 27

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

Question 28

Elderly: best option for initial treatment

Answer 28

SSRI, but bupropion and venlafaxine are second options

Question 29

Mirtazapine in elderly patients

Answer 29

Could be good in older, frail patients and have benefits in anxiety, sleep, and appetite stimulation

Question 30

Special populations: peds

Answer 30

Therapy could be useful in mild depression

Question 31

MDDs approved in peds

Answer 31

Fluoxetine for 8+, escitalopram in 12+

Question 32

Special populations: pregnancy- what med should you avoid at all costs?

Answer 32

PAROXETINE

Question 33

Pregnancy: medication approved for PPD

Answer 33

Brexanolone

Question 34

Side effects of brexanolone

Answer 34

Suicidal thoughts and behavior, flushing, infusion site reactions

Question 35

Brexanolone REMS program

Answer 35

On REMS because it can cause excessive sedation and loss of consciousness

Question 36

MDD symptom resolution timeline: week 1

Answer 36

decreased anxiety, improved sleep and appetite

Question 37

MDD symptoms resolution: weeks 1-3

Answer 37

increased activity, sex drive, self-care, memory, thinking and movements become more normal and so does sleeping and eating

Question 38

MDD symptoms resolution: weeks 2-4

Answer 38

relief of depressed mood, thoughts of suicide begin to subside

Question 39

What can be used to evaluate therapeutic outcomes?

Answer 39

Serum concentrations, side effects, remission of target symptoms, rating scales

Question 40

BBW for all MDD meds

Answer 40

Increased risk of suicidality in young adults 18-24 years of age, especially at the early stage of treatment

Question 41

The reasoning behind the BBW for MDD meds

Answer 41

Increased energy towards the beginning of treatment may help people go through with suicide plans/think of some

Question 42

What to do about the BBW for MDD meds

Answer 42

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