Depression
Posted On April 17, 2020
Treatment of Unipolar depression
Depression is a very common medical problem, prevalence is over 10% of the population. When patient has other medical symptoms such as headache, chest pain, shortness of breath, soft tissue pain, low energy, poor sleep, weakness, numbness, they will be seen by a variety of specialists and receive extensive testings and treatment.
If depression is not dealt with first, treatment of the other symptoms will has a low chance of improving.
Diagnosis
Depression: prevalence about 10%
- 5 or more of the following, nearly every day for > 2weeks
- Depressed mood
- Loss of interest or pleasure in most activities
- Insomnia or hypersomnia
- Change in appetite or weight
- Psychomotor retardation or agitation
- Low energy
- Poor concentration
- Thoughts of worthlessness or guilt
- Recurrent thoughts about death or suicide
Dysthymia
- 2 or more of the following, for over 2 years
- Decreased or increased appetite
- Insomnia or hypersomnia
- Low energy
- Poor self-esteem
- Poor concentration
- Hopelessness
Screening
- PHQ-9 – Quick depression assessment more accurate than other screen
- WHO Five Well-Being Index
- Beck depression inventory – requires a license and fee to use
Treatment
| Class | Name | Start | Max | Notes |
|---|---|---|---|---|
| SNRI | Duloxetine (Cymbalta) | 30 mg qd | 60 mg qd | |
| SNRI | Venlafaxine XR (Effexor XR) | 75 mg qd | 150 mg qd | |
| SNRI | levomilnacipran ER | 20 mg qd | approved, coming | |
| SNRI | Minacipran (Savella) | 25 mg bid | 100 mg bid | expensive $400/month |
| Serotonin mod | Trazadone | 100 mg hs | 300 mg hs | |
| SNRI, SSRI | all | may cause transient nausea | ||
| Atypical | Bupropion sr | 100 mg bid | 200 mg bid | may cause insomnia |
| Atypical | Mitrazapine (Remeron) | 15 mg hs | 45 mg hs | cause drowsiness, weight gain |
| SSRI | Citalopram (Celexa) | 10 mg qd | 40 mg qd | |
| SSRI | Escitalopram (Lexapro) | 10 mg qd | 20 mg qd | |
| Tricyclic | Amitriptyline (Elavil) | 10 mg hs | cause drowsinss, anticholinergic, weight gain | |
| Tetracyclic | Desipramine | 25 mg hs | less side effect than Amitruotyline | |
- Start with single antidepressant
- Chose drug based on safety and side effect profile
- Single antidepressant resulted in remission 30-50% of patients
- If not effective, switch to an antidepressant of a different class
- If poor response consider
- Mitrazapine plus ssri
- Mitrazapine plus buproprion
- Mitrazapine plus venlafaxine
- SSRI plus nortriptyline
- or add aripiprazole (Abilify) 2-15 mg per day
- main side effect akathisia, dose dependent
- Still resistant, or initial depression is severe, evaluate by psychiatrist