depression and anxiety 12 16 note

Antidepressant dosing and brand name:

Algorithm for depression treatment:

  • CT: cognitive behavior therapy
  • No huge difference after failing first SSRI
  • Paroxetine is most anxiolytic. Citalopram better tolerated and also has anxiolytic. Zoloft also has anxiolytic

Switching antidepressants

  • Cross titrate 2 different medications over 2 weeks

Pharmacologic treatment options for patients with treatment-resistant depression include switching to another antidepressant or augmenting with a second agent.  This patient has failed to respond to an adequate trial (>6 weeks) of high-dose fluoxetine.  Patients with little to no improvement (nonresponders) or unacceptable tolerability generally benefit from switching to another antidepressant rather than augmentation.  Discontinuing fluoxetine and starting venlafaxine, a serotonin-norepinephrine reuptake inhibitor, would be the most appropriate next step.

Partial responders, in contrast, can consider augmentation as a first-line option as switching carries a risk of losing the partial therapeutic benefit from the original drug.  Augmentation strategies include adding a second-generation antipsychotic, an antidepressant with a different mechanism of action, or occasionally lithium or triiodothyronine.

The second-generation antipsychotic aripiprazole is an effective augmentation strategy for treatment-resistant major depression.  However, it is not used as monotherapy.

Side Effects

  • Increase GI bleed with SSRI
  • Citalopram can cause increased QTc, check in elderly
  • Paxil: most anticholinergic, bad for elderly
  • Prozac: very long acting, can be too activating in elderly
  • weight gain:

Sleep

  • doxepin low dose can also help

Anxiety

  • SSRI/SNRI: first line
  • second line: benzos
    • useful for quick relief while waiting for SSRI to work