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Medication Strategies: Switch vs. Augmentation

Medication Strategies: Switch vs. Augmentation. Robert K. Schneider, MD Assistant Professor Departments of Psychiatry, Internal Medicine and Family Practice Virginia Commonwealth University The Medical College of Virginia Campus. Outline. Review “Pseudoresistance” Before Treatment

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Medication Strategies: Switch vs. Augmentation

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  1. Medication Strategies:Switch vs. Augmentation Robert K. Schneider, MD Assistant Professor Departments of Psychiatry, Internal Medicine and Family Practice Virginia Commonwealth University The Medical College of Virginia Campus

  2. Outline • Review • “Pseudoresistance” • Before Treatment • Class Choice • Switching vs Augmentation

  3. Stahl S M, Essential Psychopharmacology (2000) 6-2 Neurotransmitter Receptor Hypothesis of Antidepressant Action Decreased state due to up-regulation of receptors

  4. Stahl S M, Essential Psychopharmacology (2000) 6-3 6-4 Neurotransmitter Receptor Hypothesis of Antidepressant Action MAO inhibitor tells the enzyme to stop destroying NT Increase in NT causes receptors to down-regulate

  5. Stahl S M, Essential Psychopharmacology (2000) 6-5 6-6 Neurotransmitter Receptor Hypothesis of Antidepressant Action Antidepressant blocks the reuptake pump, causing more NT to be in the synapse Increase in NT causes receptors to down-regulate

  6. amount of NT receptor sensitivity clinical effect antidepressant introduced Stahl S M, Essential Psychopharmacology (2000) 6-1

  7. Dose too low Duration too short Wrong medication Class Augmentation “Pseudoresistance”

  8. Wrong diagnosis Psychiatric Medical Comorbid diagnoses (Medical and Psychiatric) “Pseudoresistance”

  9. Target symptoms Education Expectation Stressors Patient preference Psychotherapy Before treatment

  10. Which neuortransmitters (5HT, NE, DA) Diagnosis Target symptoms Side effects Previous medication trials Understand reason for “failure” Combined vs. monotherapy Choice of class

  11. SSRIs Venlafaxime Nafazodone Buproprion TCADs Mirtazepine Classes/Types

  12. “Start low and go slow” Severity of symptoms “Angle of decent” Previous dosage levels Dosing

  13. Multiple class failures Class specific side effects Patient preference Response vs. remission Switch vs. Augmentation

  14. NORMAL MOOD RECURRENCE RELAPSE DEPRESSION Stahl S M, Essential Psychopharmacology (2000) 5-4 acute 6 - 12 weeks continuation 4-9 months maintenance 1 or more years TIME

  15. SSRI + Trazodone PTSD GAD Target sleep Middle insomnia Nightmares Augmentation

  16. SSRI + Benzodiazepine Anxiety disorders Especially Panic and GAD Initial insomnia Augmentation

  17. SSRI + buproprion Response but still fatigued or decreased concentration Response but smoking still History of ADD or ADHD Augmentation

  18. SSRI + TCAD Response and poor sleep Response and pain Response and male or postmenopausal Augmentation

  19. Stimulants Response and decreased concentration or fatigue “Organic” etiologies Side effects at higher doses Augmentation

  20. CASES

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