Anxiety and Depression Management for General … · S Sex—deficit of desire S...
Transcript of Anxiety and Depression Management for General … · S Sex—deficit of desire S...
Anxiety and Depression
Management for
General Providers
Meaghan Rudolph RN MS PMHCNS-BCStephanie Mahnks RN MSN PMHNP-BC
Massachusetts General Hospital Dept of Psychiatry
Prevalence Current estimates indicate that 50% of the
population experience at least one mentaldisorder in their lifetime and that at least 25%have suffered a mental disorder in the past year.
At least 1/3 of office visits in primary care have adirect and explicit psychological component.
Recognition, diagnosis, treatment, and referraldepend overwhelmingly on general practitioners.
Assessment What is the patient telling me?
Their interpretation of symptoms
How this is impacting them
What is the patient NOT telling me?
Appearance, what do they look like usually?
What is different from their usual presentation?
Who and what is with them?
Take in the whole picture: movement, mannerisms, attire, gait
Start your assessment in the waiting room
*Once have some data for mood/thought disorder, be sure these are primary psych, r/o all medical causes
Depression Females > Males
Female lifetime prevalence M.D. 21.3%; dysthymia--8%
Male lifetime prevalence M.D. 12.7%; dysthymia—4.8%
Culture
May express somatic concerns more than sadness/mood
disturbance
Onset mean age of onset 40
50% onset between 20 and 50 years of age.
Risk Factor for Depression
Prior episode
Family history
Lack of social support
Stressful life event
Current substance abuse
Medical comorbidity
Depression? Reactive sadness
Emotional response to event
Few hours/days
Does not interfere with functioning
Grief
Interpersonal loss
Sadness tied to the event, no loss of self-esteem
Medical/Medication induced
Thyroid, menopause, CHF,
Caffeine, benzo, birth control, antihypertensive
Diagnostic Criteria
Depression
Depressed Mood or Loss of interestor pleasure (for two weeks)
Plus 4 or more of these: Weight/appetite change
Change in sleep
Psychomotor agitation/retardation
Fatigue/loss of energy
Feelings of worthlessness or guilt
Cognitive changes/difficulty concentrating
Thought of death/suicide
Depressive Disorders Major Depressive Disorder
Single Episode
Recurrent
Dysthymic Disorder
Milder, chronic disorder
Distinguishing feature duration (2 years)
Seasonal Affective Disorder
Depressive episodes related to seasonalvariation in light.
Depressive symptoms in fall and winter; full
remission in spring and summer
Has occurred for at least two years
SIGECAPS S Sleep—decreased or increased
I Interest—deficit; anhedonia
G Guilt—including worthlessness/hopelessness/regret
E Energy--deficit
C Concentration--deficit
A Appetite—increased or decreased
P Psychomotor activity--agitation/retardation
S Sex—deficit of desire
S Suicide—ideation/planning present
Assessment Mnemonics
To diagnosis depression need: Depressed mood/anhedonia for two weeks
PLUS 4 SIG E CAPSS Symptoms
To diagnose dysthymia Depressed mood/anhedonia for two years
PLUS 2 of *SIG E CAPSS Symptoms
PHQ-9Name: Date:
Over the last two weeks, how often have you been bothered by any of
the following problems?Not at all Several days
More than half the
daysNearly every day
Little interest or pleasure in doing things 0 1 2 3
Feeling down, depressed, or hopeless 0 1 2 3
Trouble falling or staying asleep, or sleeping too much 0 1 2 3
Feeling tired or having little energy 0 1 2 3
Poor appetite or overeating 0 1 2 3
Feeling bad about yourself, or that you are a failure, or that you have let
yourself or your family down0 1 2 3
Trouble concentrating on things, such as reading the newspaper or watching
television0 1 2 3
Moving or speaking so slowly that other people could have noticed? Or the
opposite, being so fidgety or restless that you have been moving around a
lot more than usual.
0 1 2 3
Thoughts that you would be better off dead, or of hurting yourself in some
way0 1 2 3
Total ___ = ___ + ___ + ___ + ___
PHQ-9 score ≥10: Likely major depression
Depression score ranges:
5 to 9: mild
10 to 14: moderate
15 to 19: moderately severe
≥20: severe
Bipolar DO Hallmark:
ELEVATED MOOD described as euphoric: unusuallygood, cheerful or high
EXPANSIVE QUALITY OF MOOD characterized by unceasing and indiscriminate enthusiasm forinterpersonal, sexual, or occupational interactions
Must last at least 1 week (or less ifhospitalization is required)
Uninvolved people may not recognizepathology—those who know the patientrecognize it as abnormal
Mania Assessment
DIGFAST D = Distractibility and easy frustration
I = Irresponsibility and erratic uninhibited behavior
G = Grandiosity
F = Flight of ideas
A = Activity increased with weight loss and increasedlibido
S = Sleep is decreased (but feel rested)
T = Talkativeness (noticed by others)
Substance Use Alcohol
Marijuana
Vaping
Edibles
Ilicits
Stimulants
Impact on presentation, treatment and prognosis
Treatment Modalities Collaborative Care
Psychotherapy
CBT
Interpersonal therapy
Supportive therapy
Group Therapy
Complementary techniques
Relaxation
Meditation
Exercise
Light Therapy
ECT (electroconvulsive therapy)
Psychopharmacologic
Treatment of Depression Medication
Severity of illness
Sustained physiological symptoms
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin/norepinephrine reuptake inhibitors(SNRIs)
Atypical antidepressants
Tricyclic antidepressants (TCAs)
Monamine oxidase inhibitors (MAOIs)
Treatment Efficacy of medication in general is comparable
between classes, but fine tuned to patient profile
Initial selection of medication: Target symptoms identified
Side effects/patient preference
Comorbid illness
Drug/drug interactions
First degree relative response
Cost
Characteristics of Depression
Agitated, irritable, suicidal ideation: SSRI
Apathy, low energy: dopamine, SNRI
Determining Treatment Escitalopram*
Fewer side effects
Less drug drug interactions
Citalopram
Paroxetine
Wt gain, sexual dysfunction
Sertraline
GI toxicity
Treatment with SSRIs Some patients may experience increased energy/activation early after
initiation of treatment
But onset usually delayed 2-4 weeks
If no response after 6-8 weeks
Wait- “failure” of a med is often due to adequate trial
Increase dose
When tapering UP schedule face to face/phone to assess efficacy
Increase if SE tolerable
Max dose
Change SSRI
Cross taper
Treatment may be indefinite
Best augmentation if partial response: psychotherapy
Consider augmenting with another appropriate agent
Serotonin Syndrome After initiation of serotonergic agent (24 hours)
Life theratenting
Neuromuscular hyperactivity (tremor, hyperreflexia)
Hyperthermia
Agitation, altered MS
Treatment
Discontinue agents
Supportive care to normalize VS
Serotonin antagonists
Future: determine treatment without use of serotonergic agents
Managing Side Effects Most Side Effects are Immediate, go away with time
Anorgasmia
Reduce dose
Sildenafil prn
Add bupropion
Weight Gain
Exercise
Diet
Augmenting Treatment Tolerating current SSRI well
Illness severity
Time urgency
Willingness to take other medications
Modality Additional SSRI
Additional Agent
Bupropion
Trazodone
Antipsychotic
Mood Stabilizer
Continuation and
Maintenance Continuation
After resolution of major depressive episode
Preserve and enhance remission
Relapse prevention
Maintenance
After recovery
Prevention of subsequent episodes
Pharmacotherapy 6 months +
Maintain/restore baseline functioning
Eliminate any residual symptoms
Discontinuation Syndrome Abruptly stopping SSRI
Occurs within 1-4 days
Symptoms
Dizziness
Fatigue
Headache
Nausea
Least Risk: Fluoxetine
Intermediate: Citalopram, escitalopram, sertraline
Most: Paroxetine
Management of
Discontinuation Syndrome Taper slowly as per specific drug recs/patient situation
Need to taper (adverse effect, pregnancy)
Severity of symptoms
Length of treatment (longer then 3-5 weeks requires
taper)
Longer ½ life 2-3 weeks
Shorter ½ life (<24 hours) 4 weeks
Assessment of anxiety
disorders Varies with each disorder
In the last few months have you…
Been frequently worried about several things in life?
Is it hard to control or stop worrying?
Any recurrent panic attacks?
Do experiences cause significant trouble at home or work
GAD 7
Over the last 2 weeks, how often have you been bothered by the following problems?
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
Add the score for each column Total Score (add your column scores) =
Diagnosis of Anxiety DO Inclusion and exclusion criteria
Duration
Symptoms
Modifiers and alternatives
Includes symptoms that cannot be explained by
another psychiatric disorder
Symptoms cannot be explained by:
medical condition
substance use
Generalized Anxiety Disorder
(GAD) Excessive anxiety and worry that is difficult to control
occurring more days than not for at least six months
Associated with at least three symptoms:
Restlessness, easily fatigued, difficulty concentrating,
irritability, muscle tension, sleep disturbance
r/o substance abuse; r/o medical causes
Panic Disorder Recurrent panic attacks as characterized by at least four of
the follow symptoms:
Palpitations, sweating, trembling, sensation of shortness of
breath, sensation of choking, chest pain, nausea or abdominal
pain, dizziness, chills or heat sensation, paresthesias, fear of
losing control, fear of dying
Derealization vs. depersonalization
At least one panic attack is followed by at least one month of
the following:
Persistent worry about consequences i.e. ongoing panic attacks
Maladaptive changes to avoid panic attacks
Post Traumatic Stress
Disorder (PTSD)Exposure to actual or threatened death, serious injury or sexual violation, either first hand or witnessed. Person must have at least one of the follow intrusion symptoms for at least one month following experience:
Memories, dreams, flashbacks, exposure distress, physiological reactions
In addition, affected persons must experience one of the following avoidance symptoms for at least one month following experience:
Internal reminders, i.e. avoid thoughts or feelings, External reminders, i.e. avoid people or places
In addition, affected persons must experience at least two of the following negative symptoms for at least one month following experience:
Impaired memory, negative self-image, blame, negative emotional state, decreased participation, detachment, inability to experience positive emotions
And two of the following arousal behaviors:
Irritable or aggressive, reckless, hypervigilance, exaggerate startle response, impaired concentration, sleep disturbance
Treatment Modalities SSRIs gold standard
Block serotonin reuptake pump
Desensitizes serotonin receptors, particularly 1A
receptors
Fluoxetine MDD, OCD, PMDD, bulimia nervosa, panic d/o, bipolar
depression, treatment resistant depression in combination
with olanzapine, social anxiety d/o, PTSD
has antagonist properties of 5HT2C receptors would
could increase norepinephrine and dopamine
Fluoxetine side effects: increased serotonin can cause diminished
dopamine responsible for emotional flattened, cognitive slowing, apathy
most side effects are immediate and go away with time
notable SE: sexual dysfunction, GI, CNS (insomnia, h/a), sweating, bruising
life threatening: rare seizures, induction of mania, activation of SI
weight gain and sedation are unlikely
dose range once daily: 20- 80 mg for anxiety disorders
Fluoxetine Stopping med: taper rarely necessary as med has long
half-life and will taper itself upon abrupt discontinuation
Notable drug interactions:
Tramadol: increase risk of seizures
Use with caution with TCAS as can increase level
Can cause fatal serotonin syndrome when used with
MAOIs and need to have stopped MAOI For at least two
weeks prior to starting Prozac, conversely do not start
MAOI after stopping Prozac for at least five weeks
NSAIDS may impair efficacy of SSRIs
Sertraline -MDD, panic d/o, PTSD, GAD, OCD, social anxiety d/o
Block serotonin reuptake pump
Desensitizes serotonin receptors, particularly 1A receptors
Also has some ability to block dopamine reuptake pump
Some patients may experience increased energy/activation early after initiation of treatment, however onset usually delayed 2-4 weeks
If no response after 6-8 weeks, may increase dose or may change SSRI
Treatment may be indefinite
Side effects the same
Augmentation therapies: same as above
Also rare sedation an rare weight gain
Dosing 50- 200 mg once daily
Sertraline With PMDD dose may fluctuate throughout the month
based on symptoms
Mild taper to avoid withdrawal effects: dizziness,
nausea, GI symptoms, generally 50 percent dose
reduction for three days, then repeat until discontinued
Drug interactions: same as above
Citalopram MDD, PMDD, OCD, Panic d/o, GAD, PTSD, social anxiety d/o
Block serotonin reuptake pump
Desensitizes serotonin receptors, particularly 1A receptors
Also has mild antagonist actions at H1 histamine receptors
No known activation effect, onset usually within 2-4 weeks
If no response after 6-8 weeks, may increase dose or may change SSRI
Treatment may be indefinite
Side effects similar however sedation more common due to mild antihistamine properties
Augmentation therapies: same as above
Weight gain unusual
Dose range is 20- 40 mg daily
Taper similar to Sertraline and not usually necessary
Drug interactions: same as above
Augmenting treatment trazodone: best response for insomnia
benzodiazepines: panic attacks
gabapentin: ongoing anxiety
Wellbutrin