Answer to the Depression question
Is she on the appropriate first-step regimen for her symptoms. Among antidepressants which is the most effective? . What are other pharmacological and non-pharmacological approaches for her symptoms? What is the next most appropriate and safe step in the management at this point. What is the recommended follow-up plan?
First identifying possible culprits that can be withdrawn may be useful such medications associated with depression are beta-blockers, seizure meds, Parkinson meds, Interferon.
In patients who have failed the pharmacotherapy for depression, combination treatment is thought to be superior http://content.nejm.org/cgi/content/short/342/20/1462
Our patient has may psychological stressors and in this scenario, Counselling is superior than pharmacotherapy http://www.annals.org/cgi/content/abstract/134/1/47. Unfortunately she cannot afford a psychiatrist at this place and time.
All classes of antidepressants are thought to be EQUALLY effective. However a recent Lancet meta-analysis suggested that 2 SSRIs are better: Escitalopram and sertraline were the most efficacious of 12 antidepressants.Cipriani A et al. Lancet 2009 Feb 28; 373:746
http://www.scribd.com/doc/17490227/Cipriani-Depression-Lancet-2009
Half of the patients will not tolerate an SSRI and Half will not respond. For non responders (such this lady) another pharmacological class should not be tried unless a second SSRI has been tried. IF both agents fail then switching class is recommended. After unsuccessful treatment with an SSRI, approximately one in four patients had a remission of symptoms after switching to another antidepressant.http://content.nejm.org/cgi/content/short/354/12/1231
It is common knowledge that TCAs are avoided in the elderly.
ACP guidelines recommend SSRI as the FIRST pharmacological step in treatment of depression http://www.annals.org/cgi/content/full/149/10/725 Also “ The American College of Physicians recommends that clinicians modify treatment if the patient does not have an adequate response to pharmacotherapy within 6 to 8 weeks of the initiation of therapy for major depressive disorder” If the patient has partial response after 6-8 weeks increasing the medication to maximum dose is warranted. If the patient has no response, then the medication should be changed (no washout period is necessary).
Venlafaxine or Duloxetine are safe choices (SNRI) only slighter risk for HTN than SSRI – great for patients with chronic pain. http://www3.interscience.wiley.com/journal/109629670/abstract?CRETRY=1&SRETRY=0
When SSRIs have Partial Response, after depleting our SSRI maneuvers adding buproprion has evidence based indication (Augmentaton Therapy): Augmentation with sustained-release bupropion does have certain advantages, including a greater reduction in the number and severity of symptoms and fewer side effects and adverse events. http://content.nejm.org/cgi/content/abstract/354/12/1243
Also risperidone has a role in the augmentation therapy
After a 4-week run-in period to ensure insufficient response to standard antidepressants, patients were randomly assigned to receive risperidone, 1 mg/d, or placebo for 6 weeks. After 4 weeks, the dosage of risperidone was increased to 2 mg/d in some cases. Risperidone augmentation produced a statistically significant mean reduction in depression symptoms, substantially increased remission and response, and improved other patient- and clinician-rated measures. http://www.annals.org/cgi/content/abstract/147/9/593
How can untreated depression affect a person’s physical health based on evidence.
- Depression in the setting of MI has associated increased mortality. (Relationship Between Depression and Other Medical Illnesses Steven P. Roose, MD; Alexander H. Glassman, MD; Stuart N. Seidman, MDJ AMA. 2001;286:1687-1690.)
- Depression is associated with increased fecal and urinary incontinence: http://blogogenesis.wordpress.com/2009/02/23/preventing-fecal-and-urinary-incontinence/
- Antidepressants can lead to lethal Serotonin syndrome when combined the Dextromethorphan (D-component of OTC allergy med), tramadol, levodopa, amantadine, meperidine.
This patient has depression the 4th leading cause of worldwide disability. The patient presents with multiple somatic complaints which is a characteristic and has several risk factors as well such advanced age, female gender and chronic medical illness with multiple social stressors such recent immigration.
Upon further questioning she admits that she has problems with sleep (a minor diagnostic criterion) but certainly has the 2 major criteria which are anhedonia and depressed mood (> than 2 weeks). USPSTF recommend screening for depression in the general population.
Depression: What is the next evidence-based step?
I saw a follow-up patient of mine 72 year old Russian Jewish woman with a history of depression, anxiety disorder and depression. Her medications include amlodipine 10 mg, lorazepam 20mg escitalopram 10 mg and lorazepam 1 mg po prn. She is tearful, desperate. Due to financial and insurance restrains “white card”; she cannot see a psychiatrist. She has been having these symptoms for few years. She has negative thoughts, feelings of unworthiness, lack of energy. She recently immigrated to the United States because of her children live here. She cannot speak a word of English. Currently she does not have suicidal thoughts.
I will try to look for these questions and update the current post.
1. Is she on the appropriate first-step regimen for her symptoms. Among antidepressants which is the most effective?
2. What are other pharmacological and non-pharmacological approaches for her symptoms?
3. What is the next most appropriate and safe step in the management at this point.
4. What is the recommended follow-up plan.
5. How can untreated depression affect a person’s physical health based on evidence.
Please feel free to post your response (I will accept your post if it is supported by evidence)
Cheers,
Markos
Hello world!
Welcome to the applied evidence blog. Within it’s electronic walls you will find upcoming clinical questions and answers based on the latest evidence.
Keep in mind that evidence based medicine has multiple limitations. It resembles socialized models in which what applies to the “group” applies to the individual. However, many of our decisions are individualized, our genome unique and what applies to a group of 50-70 year olds in Netherlands may not apply to 40 year olds in Baltimore.
Still, a given patient would like to know what is the most effective treatment on others with the same condition, what it the most likely cause of his or her illness etc. I found myself looking for a free database of clinical PICO questions and since I couldn’t find a satisfactory one, I have created this blog. It is a joint blog with blogogenesis.wordpress.com.
You can use the comment section to ask/answer your own clinical questions. The purpose of this blog is to keep answers brief, recognize and suspect bias and promote a clinician and not a “statistician” thinking.
Welcome.
Markos Kashiouris
