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Cheatography

Depression Cheat Sheet (DRAFT) by

Roadmap for complicated cases of depression

This is a draft cheat sheet. It is a work in progress and is not finished yet.

First Line Options: trial two medica­tions

Sertraline
Good for co-morbid anxiety, trauma history, or prominent neurov­ege­tative symptoms. Well studied in patients with cardio­vas­cular disease and depression post MI. Not ideal for patients with IBS or insomnia. Limited medication intera­ctions, can increase concen­tra­tions of statins, tramadol, but effect is weak. No dose adjust­ments in renal impair­ment, reduce dosage by 50% in moderate to severe hepatic impair­ment. Dose range 12.5-200mg daily.
Escita­lopram
Good for side effect prone indivi­duals, geriatric patients, prominent co-morbid anxiety. More potent than citalopram with better side effect profile and lower risk for QTc prolon­gation. Fewest drug intera­ctions of all SSRI's, consider with polyph­armacy. Dose range 5-30mg daily.
Citalopram
Good for patients excess­ively activated or sedated by other SSRIs. Not as well tolerated as escita­lopram, but still among the best for side effect profiles especially in the elderly. Caution in cardiac disease due to risk of QTc prolon­gation in doses over 40mg, do not exceed 20mg over age 60. May be less effective for anxiety than other SSRIs. No dose adjustment for renal impair­ment, maximum dose 20mg in hepatic impair­ment. Dose range 10-40mg daily.
Fluoxetine
Good for patients who struggle with missed doses due to long half life and active metabo­lites. Activating properties can combat lethargy and other neurov­ege­tative symptoms, and cause less weight gain. Caution in patients with anxiety and insomnia. Consid­erable inhibition at CYP2D6 and CYP3A4, therefore can legiti­mately increase levels of warfarin, tramadol, simvas­tatin, atorva­statin, beta blockers, alpraz­olam. No dose adjustment for renal impair­ment, lower dose by 50% in moderate to severe hepatic impair­ment. Dose range 10-80mg daily.
Paroxetine
Good in patients with co-morbid anxiety disorders and insomnia. Not ideal in non-co­mpl­iance due to short half life and prominent discon­tin­uation syndrome. CR formul­ation may be better tolerated. Increased sedation, sexual dysfun­ction and weight gain due to antich­oli­nergic proper­ties. Can exacerbate confusion in the elderly. Very potent inhibition at CYP2D6, commonly increases levels of warfarin, NSAIDs, beta blockers, as well as interfere with analgesic effects in some opioids. Reduce dosage by 25-50% in renal impair­ment, 50% in moderate to severe hepatic impair­ment. Dose range 10-60mg daily.
Fluvox­amine
Good for patients with OCD, co-morbid anxiety, and need for rapid onset of action. May also have less sexual dysfun­ction. Caution in IBS due to prominent GI side effects, disadv­antage of twice daily dosing. Consid­erable inhibition at CYP1A2 and CYP3A4, can reduce clearance of caffeine, alpraz­olam, simvas­tatin, atorva­statin. Smoking increases the drug clearance and lowers efficacy. Reduce dosage by 25% in renal impair­ment, 50% in moderate to severe hepatic impair­ment.
General Pearls

*Trial two SSRI's for 4-8 weeks before moving to second line

*Consider using low dose trazodone for first few weeks for initial insomnia, prn ondans­etron for nausea.

*Treat sexual dysfun­ction with bupropion, silden­afil, tadalafil, buspirone

*Treat night sweats with clonidine 0.1-0.2mg QHS or oxybutinin 5-10mg PO QHS
 

Second line options

Venlaf­axine
Good for low energy, prominent neurov­ege­tative symptoms, somatic symptoms, pain, migraines. Helpful for vasomotor symptoms in menopause. Short half life and prominent discon­tin­uation syndrome, XR formul­ation is better tolerated. Not ideal for patients with IBS, cardiac disease, or hypert­ension. Higher doses required for noradr­energic effect, will likely be needed in resistant depres­sion. Very limited drug intera­ctions. Lower dose by 25-50% in renal impair­ment, 50% in moderate to severe hepatic impair­ment.
Bupropion
Good for patients with low energy­/mo­tiv­ation, co-morbid ADHD, tobacco use disorder. Also ideal for patients concerned about sexual dysfun­ction and weight gain. Not ideal with severe co-morbid anxiety, tic disorders, eating disorders, insomnia, or seizure disorder. XL formul­ation better tolerated in general. Limited drug intera­ctions, but do not combine with nicotine replac­ement therapy due to risk of hypert­ension. No dose adjustment necessary with renal impair­ment, for hepatic impairment maximum dose is 150mg XL every other day. Dose range for XL 150mg-­450mg.
Duloxetine
Good for fatigue, somatic symptoms, pain, and co-morbid anxiety. Lower risk of hypert­ension compared to venlaf­axine. Not ideal for patients with liver disease, patients with urologic disord­ers­/pr­ostate enlarg­ement. Moderate inhibition of CYP2D6, may increase levels of beta blockers. Mild CYP1A2 inhibi­tion, tobacco use may reduce drug efficacy. Contra­ind­icated in hepatic insuff­ici­ency, no dose adjustment for renal impair­ment. Dose range 20-120mg daily.
MIrtaz­apine
Good for patients with insomnia, anxiety, appetite loss, nausea/GI issues. May have less associated sexual dysfun­ction, and have a faster onset of action. Not ideal in obesity, low energy­/fa­tigue, vulner­ability to orthos­tasis. Weight gain more common in women, occurs within first 6 weeks. Does not affect CYP450 system, minimal drug intera­ctions. Use with caution in hepatic and renal impair­ment, but no required dose adjust­ment. Dose range 7.5-45mg daily, dose at night. Sedation occurs mostly at lower doses.
Pearls:

* Try 1-2 second line options for 4-8 weeks before moving to augmen­tation strategies
 

Augmen­tation Strategies

Bupropion
Can be added to SSRI or SNRI for potent­iation of antide­pre­ssant effect, increase energy and improve cognit­ion­/co­nce­ntr­ation. Can also improve sexual dysfun­ction. Monitor BP when adding to SNRI.
Mirtaz­apine
Can be added to SSRI or SNRI to potentiate antide­pre­ssant effect, improve insomnia, anxiety or appetite. Tends to be more sedating at lower doses (7.5 and 15mg)
Buspirone
Can be added in co-morbid genera­lized anxiety, or for mitigation of sexual side effects.
Aripip­razole
Can be added to SSRI or SNRI in cases with low energy­/mo­tiv­ation, prominent intrusive or obsessive thinking patterns, and agitation. Has the best evidence of all augmen­tation strate­gies. Also a good choice in patients concerned about weight gain. Effective dose range is 2-10mg daily. Common side effects include dizziness, consti­pation, nausea, and akathisia. No dose adjustment necessary for renal or hepatic impair­ment. Fluoxe­tine, fluvox­amine, and paroxetine will increase plasma levels. Check BMI, lipids, A1c at 1,3, and 6 months then yearly.
Quetiapine
Can be added to SSRI or SNRI in cases with insomnia, anxiety, agitation, obsess­ive­/in­trusive thinking patterns. Not ideal for patients with severe obesity or type II diabetes. Common side effects include sedation, dry mouth, orthos­tasis, weight gain, akathisia. Very low incidence of extra-­pyr­amidal symptoms. Generally dosed initially at 25-50mg PO QHS, then titrated to 150-300mg for optimal antide­pre­ssant effect. Limited drug intera­ctions, can rarely increase warfarin levels. No dose adjustment in renal impair­ment, reduce dose by 25-50% in hepatic impair­ment. Check BMI, lipids, A1c at 1,3 and 6 months.
Lithium
Can be added to SSRI or SNRI in cases with prominent emotional dysreg­ula­tion, chronic suicidal thinking, anxiety, obsess­ive­/in­trusive thinking patterns. Used at low doses as adjunct to antide­pre­ssant, start at 150mg PO QHS and titrate up to 300-600mg PO QHS. Check level 5-7 days after initia­tion, and after each dosage increase. Maintain lower blood levels, generally 0.6-0.8. Levels should be checked at 12 hours after last dose to obtain true trough. When stable dose is reached switch to CR formul­ation and dose at night. Common side effects include nausea, mild tremor, sedation, weight gain, polyuria, polydi­psia, and hypoth­yro­idism. Not recomm­ended in renal insuff­ici­ency, no dose adjustment necessary for hepatic insuff­ici­ency. NSAIDs, thiazide diuretics, COX-2 inhibi­tors, ACE inhibi­tors, calcium channel blockers can all increase lithium levels. Monitor levels during GI illness or any condition that involves fluid shifts or dehydr­ation. Check BMP, TSH at baseline then at 1,3, and 6 months.
Liothy­ronine
Can be added to SSRI or SNRI in cases with severe fatigue, weight gain, cognitive slowing. Not ideal in patients with anxiety, eating disorders, hypert­ension. Low doses 5-25mcg are suffic­ient, monitor for sympto­matic hypert­hyr­oidism. Common side effects include anxiety, insomnia, appetite loss. Studies suggest only mild benefit.
Modafinil
Can be added to SSRI or SNRI in cases with co-morbid OSA, fatigue, cognitive diffic­ulties, poor sleep patterns due to shift work. Not ideal in prominent anxiety, insomnia, hypert­ension. Common side effects include headache, nausea, insomnia, anxiety, palpit­ations, appetite loss. May increase levels of propra­nolol, through CYP2C19 inhibi­tion, reduces levels of warfarin, contra­cep­tives. Effect is inhibited by prazosin or other alpha 1 blockers. Less abuse potential compared with stimul­ants. Dose range is 100-200mg daily. Dose reduction of 50% in both renal and hepatic impair­ment.
Lamotr­igine
Can be added to SSRI or SNRI in cases with severe emotional dysreg­ula­tion, family history of bipolar disorder, impulse control issues. Can be used as mono therapy for depression in patients intolerant of SSRI/SNRI. Very well tolerated without associated weight gain, sedation, or sexual dysfun­ction. Risk of SJS/TENS is low, just adhere to standard dosing schedule for initia­tion. Patients missing 5 or more consec­utive doses need to be re-tit­rated. Common side effects include blurred vision, ataxia, nausea. 10% develop a benign rash. Do not administer with valproic acid, this can increase risk of SJS. Dose range is 25-400mg, start 25mg QD x 14 days, then 50mg PO QD x 14 days, then increase to 100mg daily. Dose reduction of 50% in renal impair­ment, 25% in moderate to severe hepatic impair­ment.
Methyl­phe­nidate
Can be added to SSRI or SNRI in cases with severe fatigue and lack of energy­/mo­tiv­ation. Safe and well tolerated in geriatric depression or post stroke depres­sion, generally doses are low 5-20mg daily. Not ideal for patients with substance use disorders, anxiety, insomnia, loss of appetite. Safer and better tolerated than amphet­amine prepar­ations. Limited drug intera­ctions, no dose adjustment necessary for renal or hepatic impair­ment. Caution in patients with coronary artery disease, monitor BP at each visit.
Pearls:

*Treat akathisia with propra­nolol 10-20mg PO BID

*Can initiate metformin with atypical antips­ych­otics, which will likely prevent associated metabolic effects

*Treat lithium induced hypoth­yro­idism with levoth­yro­xine, polyuria can be treated with amiloride