pharmacotherapy of depression and anxiety

1. Pharmacotherapy of Depression and Anxiety Vickie Corbett Ripley, PharmD, BCPP Clinical Pharmacist Practitioner Coastal Plain Hosptial Rocky Mount, NC

3. Limbic System Dysfunction

4. Spectrum of Psychiatric Disorders

5. Neurotransmitters and Psychiatric Pharmacotherapy

6. Phases of MDD Treatment

7. Recurrence After Recovery from Major Depression

8. Diagnosis of mental illness DSM IV (Diagnostic and Statistical Manual of Mental Disorders � 4th edition) Lists criteria necessary to meet diagnosis Useful for standardizing diagnoses To meet most diagnoses generally must Interfere with social or occupational functioning Must be interpreted in context of culture Psychiatry is somewhat different from other medical specialties in that for the most part, rather than relying on labs and objective measures, diagnoses is based on subject report DSM-I introduced in 1950�s was the first manual to contain a description of diagnostic categories Culture � 1) somebody involved in trance ceremony in native american culture in which they are hearing from deceased ancestors are not psychotic b/c it within culture; jimmy swagard hears from g-d, OK if within cultural contextPsychiatry is somewhat different from other medical specialties in that for the most part, rather than relying on labs and objective measures, diagnoses is based on subject report DSM-I introduced in 1950�s was the first manual to contain a description of diagnostic categories Culture � 1) somebody involved in trance ceremony in native american culture in which they are hearing from deceased ancestors are not psychotic b/c it within culture; jimmy swagard hears from g-d, OK if within cultural context

9. Multiaxial Assessments Axis I � Clinical Disorders Axis II � Personality disorders and mental retardation Axis III � General medical conditions Axis IV � Psychosocial and Environmental problems Axis V � Global assessment of functioning (GAF) Axis II � often in chart will see it say �deferred�, means that at the time of the evaluation there was insufficient information to make any diagnostic judgment about an axis II diagnosisStressors are rated on a scale of 1 (none) to 6 (catastrophic) and can be acute (lasting less than 6 months) or enduring. Examples include difficulties with primary support group (i.e. death of a family member, divorce) , problems related to social environmetn (living alone, adjustment to life cycle transition such retirment), educational problems, occupational problems, housing probkems, economic problems, problems with access to health services or legal problems. GAF � rated on a scale of 1 (persistent danger to self or others) to 100 (superior functioning, life�s problems never seem to get out of hand). Axis II � often in chart will see it say �deferred�, means that at the time of the evaluation there was insufficient information to make any diagnostic judgment about an axis II diagnosisStressors are rated on a scale of 1 (none) to 6 (catastrophic) and can be acute (lasting less than 6 months) or enduring. Examples include difficulties with primary support group (i.e. death of a family member, divorce) , problems related to social environmetn (living alone, adjustment to life cycle transition such retirment), educational problems, occupational problems, housing probkems, economic problems, problems with access to health services or legal problems. GAF � rated on a scale of 1 (persistent danger to self or others) to 100 (superior functioning, life�s problems never seem to get out of hand).

10. Axis I disorders Mood disorders Major depressive disorder Bipolar disorder Anxiety disorders Generalized anxiety disorders Panic disorder Social phobia Obsessive Compulsive Disorder Psychotic disorders - schizophrenia

11. DSM IV Classification of Major Depressive Episode Depressed mood and/or loss of Interest present during a two week period Plus at least FOUR of the following symptoms: Weight change Sleep disturbance Psychomotor agitation or retardation Loss of energy Feelings of worthlessness/guilt Loss of ability to concentrate Suicidal ideations

12. Psychiatric Patient Presentation Chief Complaint History of Present Illness Past Medical History Family and Social Histories Medications Allegies Review of Systems Physical Examination Mental Status Exam Appearance, behavior, and speech Mood and Affect Sensorium Intelligence Thought process Labs

13. Symptoms of Depression and Serotonin Function Depressed or elated Mood Appetite changes Sleep changes Decreased libido Increased pain sensitivity Circadian rhythm disturbances Body temperature changes

14. Physical and Social Functioning in Depression and Chronic Illness

15. Symptoms of Depression (Sig: E caps) S Sleep I Interest G: Guilt E Energy C Concentration A Appetite P Psychomotor retardation S Suicidality

16. Treatment choices Psychotherapy Light Exercise Diet Medication Medication and Psychotherapy Electroconvulsive therapy (ECT)

17. Psychotherapies Interpersonal therapy Cognitive therapy Behavior therapy Group therapy Interpersonal � Dep resulting from pts relations with other people, work or marital problems Cognitive � dep resulting from self defeating thoughts, irrational beliefs Behavior therapy � social learning therapy, activity scheduling, problem solving Group therapy � bereavement, chronic illness, med maintenance support groups Interpersonal � Dep resulting from pts relations with other people, work or marital problems Cognitive � dep resulting from self defeating thoughts, irrational beliefs Behavior therapy � social learning therapy, activity scheduling, problem solving Group therapy � bereavement, chronic illness, med maintenance support groups

18. Psychotherapy Less severe Less chronic Nonpsychotic Previous positive response Medical contraindication to medication

19. Algorithm for Treatment of Uncomplicated Major Depression 1st line: Favorite SSRI or TCA Failed trial: switch to alternative Partial response - increase dose, switch or augment Fully remits (maintain at least 4 to 6 months or longer) 2nd line: Switch or Augment Switch to other favorite - TCA or SSRI Augment with Li or TCA plus the SSRI (consult with psychiatrist) 3rd line: Failed or Partial response to 2nd line Consult with psychiatrist Switch (nefazodone, mirtazepine, bupropion, venlafaxine) Augment with Li or TCA plus the SSRI

20. Target Symptoms and Therapeutic Response Rates Week One: anxiety insomnia decreased appetite Weeks two and three: increase in energy increase suicide risk increase in libido Up to 4 to 8 Weeks: Improvement in dysphoria or sadness improvement in pessimism improvement in anhedonia

21. Treatment strategies if no response Confirm compliance Maximize dose Change drug Combine antidepressants Augmentation therapy

22. Augmentation medications Lithium AED�s Stimulants Thyroid Estrogen Sleep aids Pain meds

23. Melancholic Depression Clinical Presentation Subtype of severe depression Nearly complete absence of capacity for pleasure Diurnal mood swings (worse in the morning) Excessive guilt and weight loss Unclear if SSRI�s as effective as TCA�s in treatment Some data indicate that mirtazapine and venlafaxine more effective than SSRI�s

24. Atypical Depression Clinical Presentation Weight gain or increased appetite Hypersomnia Heavy feeling in arms or legs (leaden paralysis) Interpersonal rejection sensitivity MAOI�s greater efficacy than TCA�s Efficacy of SSRI�s relative to MAOI�s unclear

25. MDD with psychotic features Clinical Presentation: Delusions or hallucinations present during depressive episodes Usually need an antidepressant and an antipsychotic

26. Differentiation Between Depression and Dementia Area Depression Dementia Depression history (self/family) Present Absent Depression symptoms precede cognitive deficit Present Absent Duration of Symptoms Weeks Months-Years Cognitive Deficit Complains Silent Concern Cognitive Function Test  Performance deficits Inconsistent Consistent Response to MSE questions "I don't Know" Attempts to answer Effort on Testing Little Tries hard

27. Psychiatric Pharmacotherapy

28. Serotonin receptors 5-HT 2 agitation akathisia anxiety panic attacks insomnia sexual dysfunction

29. Serotonin receptors 5-HT 3 nausea gastrointestinal distress diarrhea headache

30. Dopamine receptors Stimulation can lead to agitation aggravation of psychosis

31. Norepinephrine receptors Stimulation can lead to activation hypertension panic

32. Alpha 1 adrenergic receptors Blockade can lead to dizziness orthostatic hyotension reflex tachycardia

33. Histamine receptors (H1) Blockade can lead to sedation weight gain

34. Muscarinic cholinergic receptors Blockade can lead to blurred vision dry mouth sinus tachycardia constipation urinary retention memory impairment

35. Medications TCA MAOI SSRI SNRI (venlafaxine) NDRI (buproprion) NaSSA (mirtazipine) SARI (nefazadone) SNRI � serotonin/norepi reuptake inhibitor NDRI � norepi/dopamine reuptake inhibitor NaSSA � noradreneric and specific serotonergic antidepressant SARI � serotonin antagonist/serotonin reuptake inhibitorSNRI � serotonin/norepi reuptake inhibitor NDRI � norepi/dopamine reuptake inhibitor NaSSA � noradreneric and specific serotonergic antidepressant SARI � serotonin antagonist/serotonin reuptake inhibitor

36. SSRI and New AntidepressantsMetabolism

37. Antidepressant Side Effects Drug Sedation Anticholinergic Orthostatic Amitriptyline ++++ +++ ++++ Doxepin ++++ +++ +++ Nortriptyline +++ +++ ++ Desipramine ++ ++ +++ Trazodone +++ - +++ Bupropion - + - Fluoxetine -/+ - - Sertraline -/+ - - Paroxetine ++ + - Venlafaxine +/++ + + Nefazodone ++ + + Mirtazapine ++++ ++ +

38. Single mechanism drugs Mostly noreinephrine desirpramine buproprion Mostly serotonin SSRI�s nefazadone

39. Serotonin reuptake Inhibition Norepinephrine reuptake inhibition Anticholinergic effects Alpha1 blockade Histamine blockade Tricyclic Antidepressants

40. Tricyclic Antidepressants Useful in the treatment of a number of conditions Depression Migraine prophylaxis Neuropathic pain Obsessive compulsive disorder (Clomipramine) Enuresis Panic disorder Sleep disorders Attention deficit / hyperactivity disorder

41. Tricyclic Antidepressants Clomipramine (Anafranil) 25-250mg Amitriptyline (Elavil) 50-300mg Doxepin (Sinequan) 25-300mg Imipramine (Tofranil) 30-300mg Desipramine (Norpramin) 25-300mg

42. Tricyclic Antidepressant Secondary amine Desipramine (Norpramine) Nortriptyline (Pamelor) Protriptyline (Vivactil) Tertiary amine Amitriptyline (Elavil) Clomipramine (Anafranil) Imipramine (Tofranil) Doxepine (Sinequan) Trimipramine (Surmontil)

43. With most TCA�s start with 50 mg and increase by 25 to 50 mg every 3 days (lower for nortriptyline or protriptyline) Tricyclic Antidepressant

44. TCA plasma concentrations Nortriptyline - Curvilinear conc/response profile 50 to 150 ng/ml Desipramine 125 to 300 ng/ml Imipramine 200 � 300 ng/ml Not routinely performed but can be useful in certain situations Should be obtained at steady state (at least 1 week after initiating or dose change)

45. TCA Adverse Events Anticholinergic effects Antihistaminic effects Alpha1 adrenergic blockade Sexual dysfunction Cardiac conduction delays Can result in arrhythmias in overdose Decreased seizure threshold Toxic in overdose Do not use in acutely suicidal patients

46. Preferred uses of TCA�s Depression with Pain Fibromyalgia Migraine insomnia

47. Least preferred uses of TCA�s Patients in whom anticholinergic effects would be problematic Overweight patients Suicidal patients Cardiac patients Patients with dementia

48. Selective Sertotonin Reuptake Inhibitors (SSRI�s) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Fluvoxamine (Luvox) Citalopram (Celexa) Escitalopram (Lexapro)

49. Uses of SSRI�s Depression Social phobia Panic disorder Obsessive compulsive disorder Bulimia Nervosa Post Traumatic Stress Disorder Pre Menstrual Dysphoric Disorder (Sarafem)

50. SSRI Dosing Dosing Fluoxetine -- 20 to 60 mg Paroxetine -- 20 to 50 mg Sertraline -- 50 to 200 mg Fluvoxamine -- 100 to 300 mg Citalopram -- 20 to 60 mg Escitalopram � 10 to 40 mg Relatively safe in overdose Relatively safe in patients with cardiovascular disease

51. SSRI Adverse Effects Gastrointestinal Nausea, vomiting, diarrhea Sexual dysfunction Headache insomnia Fatigue Agitation Akathesia and dystonic reactions 5HT can reduce DA levels

52. Differences between SSRI�s Most likely to cause sedation Paroxetine, fluvoxamine Paroxetine Mild anticholinergic effects Fluoxetine Higher rates of anxiety and nervousness Sertraline More diarrhea

53. When to use SSRI First line monotherapy Depression Anxiety (start with low doses) OCD Panic

54. Least preferred use of SSRI Patients with sexual dysfunction Patients with secondary refractoriness Patients with nocturnal myoclonus Patients with consistent agitation Patients with consistent insomnia

55. SSRI Withdrawal Syndromes More likely to occur with short t1/2 agents (paroxetine warning) May affect up to 1/3 of patients and more likely to be reported with short half-life agents May be due to sudden decrease in available synaptic 5HT in face of down-regulated receptors Onset in 24 to 72 hours and last up to 7-14 days Symptoms: dizziness, nausea, lethargy, headache, flu-like symptoms, parasthesia (electrical �shock-like� sensations)

56. Discontinuation syndrome Worse with short acting drugs Taper dose Flu-like symptoms Anxiety GI distress Mood, appetite, sleep changes

57. Serotonin Syndrome Symptoms Altered mental status � confusion, agitation Autonomic dysfunction � diaphoresis, tachycardia, BP changes, fever Neuromusucular abnormalities � clonus Allow 2 weeks between MAOI and other antidepressant administration 5 weeks for fluoxetine

58. Serotonin Syndrome Occurs when several serotonergic drugs combined Often involves MAOI�s as one of the drugs Other serotonergic drugs implicated SSRI�s TCA�s Serotonin releasing agents (i.e. MDMA or �ecstasy�) Dextromethorphan, meperidine, others

59. Potent 5HT2 receptor antagonist Relatively weak 5HT reuptake inhibition Alpha1 receptor blockade Metabolism: OH-Nefazodone = 1.5 - 4 hours triazole-dione = 18 hours mCPP = 4-8 hours Usual Dosage: 300 - 600 mg/day in 2 divided doses Preserves sleep architecture Potent CYP3A4 inhibitor Nefazodone (Serzone, Bristol-Myers Squibb)

60. Therapeutic uses of nefazadone depression in association with anxiety, agitation, sleep disturbances Prior SSRI induced sexual dysfunction Inability to tolerate SSRI�s Tolerance to SSRI�s

61. Lest preferred use of nefazadone Patients with hypersomnia Non-compliance with BID dosing Retarded depression Patients with difficulty with dose titration

62. Dual-Action Drugs Norepinephrine and serotonin clomipramine venlafaxine mirtizapine

63. NaSSA Noradrenergic and specific serotonergic antidepressant mirtazipine (Remeron) 15-90mg

64. Mirtazapine (Remeron�, Organon) Initial Dosing: Start with 15mg qd (hs) (supplied as 15 and 30 mg tablets) Average effective dose is 20-25mg qd Maximum dose=45mg qd Half life Women have longer half-life than men 37 vs 26 hours Half-life allows for qd dosing Dosage adjustments: Any dosage should be made after one to two weeks Adjust dose for hepatic disease Slow titration in the elderly

65. Mirtazapine (Remeron, Organon) Receptors: -5HT2 and 5HT3 antagonist, histamine 1, minimal activity on alpha 1, muscarinic, and dopamine Common Side Effects: Somnolence, dry mouth, weight gain Cautions: Can precipitate mania, hepatotoxicity (dose adjust in hepatic disease) Drug Interactions: additive cognitive and motor CNS depression, Metabolized by CYP2D6, 1A2, 3A4,Wait 14 days after stopping MAOI Dosing: Start with Start with 15mg qd, usually 20-25 mg qd, maximum dose = 45mg qd

66. Therapeutic uses of mirtazapine Depression with anxiety or agitation Depression with insomnia Problems with SSRI�s Weight loss Severe depression Loss of response to SSRI�s

67. Least preferred uses of mirtazapine Hypersomnia Motor retardation Cognitive slowing overweight

68. SNRI Serotonin/norepinephrine reuptake inhibitor venlafaxine (Effexor) 75-375mg

69. Serotonin reuptake inhibition Norepinephrine reuptake inhibition Dopamine reuptake inhibition Usual dose: 75 to 225 mg Venlafaxine (Effexor, Wyeth-Ayerst)

70. Therapeutic uses of venlafaxine At low doses, use as an SSRI At high doses has dual action Patients with hypersomnia Patients with GAD Patients with weight gain

71. Least preferred use of venlafaxine Agitated patients Patients with sexual dysfunction Patients with insomnia Patients with labile HTN

72. Venlafaxine Adverse Effects Nausea, constipation Headache Dizziness Nervousness Somnolence Dry mouth Sexual dysfunction Increased blood pressure (monitor closely)

73. NDRI Norepinephrine/dopamine reuptake inhibitor buproprion (Wellbutrin) 200-450mg

74. Therapeutic uses of buproprion Patients with retarded depression patients with hypersomnia Non-responders to SSRI�s Non-tolerators of SSRI�s Patients concerned about sexual dysfunction Patients concerned about weight gain Patient with cognitive slowing

75. Least preferred use of buproprion Patients with seizure disorders Patients who are seizure prone Patients with head injury Patients non-compliant with multiple daily doses Patients with agitation Patients with insomnia

76. Comparative Safety and Tolerability Summary Nausea Common with all Dose related, dissipates with use Diarrhea- higher incidence with Sertraline Dry Mouth- VEN, NEF > PAR, SER > FLU, FVX Anorexia- More likely with Fluoxitine, Venlafaxine Anxiety/nervousness- More common with Fluoxitine Sexual Dysfunction- all SSRIs, Ven > Nefazodone

77. Monoamine Oxidase Inhibitors (MAOI�s) Used in patients with atypical MDD/ anxiety Phenelzine (Nardil) Tranylcypromine (Parnate) Hypertensive crisis can occur when combined with high tyramine foods or sympathomimetics Aged cheeses, sour cream, wines, beer, canned or processed meats, fermented foods, coffee, chocolate Amphetamines, ephedrine, other decongestants Doses: Phenelzine � 15 to 90 mg Tranylcypromine � 20 to 60 mg

78. MAOI adverse effects All agents Sexual dysfunction Mild anticholinergic effects More likely with phenelzine Orthostatic hypotension Sedation More likely with tranylcypromine Insomnia

79. Drugs Metabolized by Human Liver Cytochromes P450s

80. Inhibition of Cytochromes P450

81. 1A2substrates/inhibitors Antispychotics TCA�s Fluoroquinolones theophylline

82. Drug interactions 1A2 Fluvoxamine ++++

83. 2D6substrates/inhibitors Antiarrhythmics Antipsychotics Beta blockers Opiates TCA�s

84. Drug interactions 2D6 Fluoxetine ++++ Sertraline + Paroxetine ++++ Venlafaxine +?

85. 2Csubstrates/inducers/inhibitors Barbiturates NSAIDS Warfarin Antifungals TCSA�a

86. Drug interactions 2C Sertraline ++ Fluoxetine ++ Fluvoxamine ++

87. 3A4 substrates/inducers/inhibitors Antiarrhythmics Antifungal Antihistamines Antipsychotics Barbiturates Benzodizepines Calcium channel blockers Grapefruit juice TCA�s

88. Drug interactions 3A4 Sertraline + Fluoxetine ++ Fluvoxamine +++ Nefazadone ++++

89. Drug Interactions - Herbal Remedies St. John�s Wort (Hypericum perforatum) Drugs that interact with MAOIs Ginko (Ginko biloba) Anticoagulants (2 cases), or ASA Kava (Piper methysticum) Benzodiazepines (1 alprazolam case), alcohol Ginseng (Siberian ginseng) potentiates MAOIs, stimulants (caffeine) and haloperidol Yohimbine (Pausinystalia yohimbine) a2 antagonist TCA, MAOIs, antimuscarinic agents potentiate yohimbine

90. St. John�s Wort Reduces the AUC of the HIV-1 PI Indinavir Open-label, Eight healthy volunteers (6M/2F) 29-50 yo Indinavir 800 mg orally(q8h x4) Blood samples 0-8 hours (AUCss) Before and after SJW 300 mg tid x 14 d (Hypericum Buyers Club) AE�s: taste changes (50%), nausea (25%), circumoral paresthesias (25%) associated with indinavir. Reduced intensity and duration with SJW. Increased resistance and Tx failure?

91. Basic algorithm Monotherapy Allow time for drug to work (4-6 weeks) Symptoms will resolve gradually Maximize dose

92. Selection of Antidepressant Presenting symptoms Previous response Family history Neurotransmitter profile Co-morbid conditions Human data Side effect profile Potential drug interactions Patient age Compliance Cost

93. Monitoring Antidepressant Therapy Monitor antidepressant regimen Is the dosage appropriate? Response favorable and adequate? Side effects present? Review new chart entries New orders? New Diagnoses? Changes in life events? Review progress notes Physician, nursing, social service, psychiatric service Continue therapy 9-12 months if first episode. If multiple: chronic maintenance

94. Clinical Management of Treatment Emergent Adverse Effects Continuation of current pharmacotherapy Dose Reduction Trial period of discontinuing medication Antidepressant substitution Adjunctive therapy (cases reported)

95. Combining other medications Add augmentation therapy Consider drug interactions Monitor other medications - OTC�s and herbals - beta blockers - steroids

96. Combining medications Use two drugs with different mechanisms SSRI plus venlafaxine mirtazipine buproprion nefazadone Or combinations of non SSRI�s

97. Depression Co-Morbidity

98. Concurrent medical disorders Asthma - avoid MAOI Cardiac disease - avoid TCA Dementia - avoid TCA and other anticholinergic drugs Seizures - avoid buproprion and TCA Glaucoma - avoid TCA HTN - watch orthostasis

99. Antidepressant Selection in the Cardiac Patient Avoid concomitant Type IA antiarrhythmics (TCA with quinidine or procainamide) BUP, SSRIs, VFX, SRZ appear to be low risk for arrhythmias and orthostatic hypotension Venlafaxine is associated with increases in BP MAOIs, Trazodone, maprotiline, amoxapine, SSRIs, and venlafaxine have not been well studied in CHF

100. Comorbid MDD and Cardiac Disease Tricyclic antidepressants complicate and/or are contraindicated in specific cardiac conditions Hx ventricular arrhythmia subclinical sinus node dysfunction conduction defects (including asymptomatic) prolonged QT intervals recent history of myocardial infarction Consider using bupropion, fluoxetine, sertraline, paroxetine, nefazodone, citalopram or ECT

101. Comorbid MDD and Cardiac Disease MAO inhibitors may induce orthostatic hypotension and lead to drug-drug interactions Monitor patient for emergence of cardiac symptoms, ECG changes, or orthostatic BP decrements Major depression is a major risk factor for increased cardiac morbidity and mortality.

102. Depression and Coronary Artery Disease

103. Case of JC 30 year old, married female, 4 children Feelings of helpless, hopeless, worthless, guilt Started with birth of last child 6 months ago Sleepy and tired all the time, no energy East too much Decreased libido No interest in much FH + depression No other medical problems

104. Case of BH 54 year old married female, 2 children grown 30 year hx MDD Multiple medications have been tried Medical Dx � fibromyalgia, IBS, chronic sinusitis Meds � Remeron. Lortab, Bently, Allegra D, various OTC and herbals Previous Ads � Prozac, Paxil, AMI, Effexor, Zoloft, Serzone, Celexa, �everything else� c/o weight gain, still depressed

105. MDD Presentation in Late Life Often lacks family history of depression Highest Suicide risk of all age groups twice the risk in elderly white males less in elderly black males same in females Often associated with medical illness Stroke (50% develop clinically significant depression) Parkinson�s disease (40 to 90% have associated depression) Typically seen by primary care physicians and may need referrals to mental health specialist for certain aspects of treatment

106. Diagnosis and Treatment of Depression in Late Life Recognition may be more difficult in late life �normal aging� and overshadowed by physical illness Similar social and demographic risk factors: female sex, single (esp. widowed), stressful life events, lack of supportive social network Treatment with sufficient: doses (plasma concentrations) of antidepressants length of treatment (e.g. at least 6 to 12 weeks in the elderly) to maximize likelihood of recovery maintenance treatment for 6 to 12 or more months

107. MDD Symptomatology in Late Life Symptoms: irritability, agitation, somatic delusions Somatic complaints: pain syndromes (general, headache, chest, GI), cardiac (palpitations, tightness), abdominal (constipation) Loss of interest or pleasure may appear as apathy

108. Symptomatology in Late Life (cont�d) Difficulty in concentration may appear as inattentiveness Disorientation, memory loss, distractibility as �dementia� 10% of �senile or pseudo dementia� is actually depression (now called �dementia syndrome of depression�) depression can coexist with dementia Heterogeneity of geriatric depression (early Vs late onset) early onset has more recurrences, more (+) family history

109. Response to Effective Treatment of Depression in Late Life Majority should expect partial or complete remission of depressive symptoms Amelioration of pain and suffering associate with physical illness Enhancement of general mental, physical and social functioning Minimization of cognitive disability

110. MDD Presentation in the Elderly �R.M., a 71-year-old male, is brought for psychiatric evaluation by his daughter, C.M., with whom he has been living for the past 3 years. C.M. reports that R.M. had been in good health until 3 months ago when he was noted to keep to himself and began showing little interest in his usual activities. She reports that he used to be a happy, very outgoing personality He has lost weight over the past 4 months, has been noted to be irritable, anxious, and has trouble falling asleep. He also frequently becomes agitated over insignificant things. He has appeared on occasion to be confused and slow in understanding concepts. ....�

111. MDD Presentation in the ElderlyCont�d �...His recent physical examination is normal except for benign prostatic hypertrophy (BPH). Laboratory examinations are WLN except for a subnormal serum creatinine. He currently is on no medication except for a daily stool softener and a bulk laxative. Mental Status Examination reveals a thin, nervous, sad-appearing man. His responses to questions are slow. Affect is sad. He shows no signs of delusions or hallucinations. He shows mild impairments in his ability to think through problems and mathematical exercises. He denies suicidal ideation but feels hopeless at the present time.�

112. MDD Presentation in the Elderly �How does a depressive episode in late life, such as that in R.M., differ from a depressive episode earlier in life?� �What is R.M.�s differential diagnosis?� �Should R.M. be placed on antidepressant therapy?� What factors would influence drug selection?

113. The Case of R.M., Cont�d How does the pharmacokinetic profile of the SSRI�s affect your choice? What are the significant drug interacts that should be considered with R.M.�s pharmacotherapy if treatment for other common disorders were added?

114. For a first episode of depression patients should be on medication for at least 12 months

115. For a second episode of depression, the patient should be on medication for 2 to 3 years

116. For a third episode of depression, most patients stay on medication for life

117. When deciding to take a patient off an antidepressant, the patient�s medical and psychosocial situations must be considered

118. Patient education Do not perpetuate the stigma of psychiatric illness Treat the patient with the same empathy, respect and concern you would treat a patient with a medical disorder Explain depression as a medical disorder Do not be afraid to discuss the signs and symptoms of depression

119. Patient education Encourage compliance with medication Help patients understand the medications and common side effects Help patients understand there is no magic bullet, but most people are successfully treated

120. Questions ?