26 February guidelines for the use of.pdf

3.1 Describe the guidelines for the use of different antidepressant medication.
3.2 Demonstrate skills in giving tricyclic and tetracyclic medication, as well as selective-serotonin re-uptake inhibitors.

1. Interpret the
guidelines for the
use of
antidepressant
medication.
Pharmacology 3

2. Objectives
•3.1Describe the guidelines for the use of different antidepressant
medication.
•3.2Demonstrate skills in giving tricyclic and tetracyclic medication,
as well as selective-serotonin re-uptake inhibitors.

3. Depression
•Depression is a common disorder, which often leads to poor quality of life
and impaired role functioning.It is known to be a major contributor to the
global burden of diseases and according to World Health Organization
(WHO), depression is the fourth leading cause of disability worldwide and
it is projected that by 2020, it will be the second most common leading
cause of disability.
•Depression is also associated with high rates of suicidal behaviourand
mortality.
•When depression occurs in the context of medical morbidity, it is
associated with increased health care cost, longer duration of
hospitalization, poor cooperation in treatment, poor treatment
compliance and high rates of morbidity.

4. Depression
•Depression is also known to be associated with difficulties in role
transitions and poor role functioning.
•It is also reported to be a risk factor for the onset and persistence of
a wide range of secondary disorders.
•Available data also suggests that between one-third and one-half of
patients also experience recurrence of depressive episodes.

5. EXAMPLE
Depression is also known to be associated with difficulties in role transitions (e.g., low education,
high teen child-bearing, marital disruption, unstable employment) and poor role functioning.
•John,a27-year-oldman,hasbeenexperiencingsymptomsofdepressionforthe
pastfewmonths.Ashereflectsonhislife,henoticesseveralchallengeshehas
facedinrecentyears.Afterdroppingoutofhighschoolduetofamilyissues,John
foundhimselfinunstableemploymentsituations,strugglingtomaintainasteady
job.Hislackofeducationlimitedhisjobprospects,andheoftenfoundhimselfin
low-payingpositionswithlittlejobsecurity.Attheageof19,Johnbecamea
fatherunexpectedly,whichledtosignificantstressandresponsibilityatayoung
age.Thisearlytransitionintoparenthooddisruptedhisplansforfurther
educationorcareeradvancement.Asheattemptedtonavigatethechallengesof
parenthoodandfinancialstrain,John'srelationshipwithhispartnerbecame
strained,leadingtofrequentargumentsandadeclineinmaritalquality.Despite
hisefforts,Johnfounditincreasinglydifficulttoperformwellatwork.His
concentrationwaspoor,andhefrequentlycalledinsickduetooverwhelming
feelingsofsadnessandhopelessness.Asaresult,hisearningsremainedlow,
furtherexacerbatinghisfinancialstruggles.

6. Example
Depression is a risk factor for the onset and persistence of a wide range
of secondary disorders.
•Sarah, a 35-year-old woman, has struggled with chronic stress for most of her
adult life. Growing up in a dysfunctional family environment characterized by
emotional neglect and abuse, Sarah experienced significant trauma during her
formative years. Despite her efforts to overcome these early challenges, Sarah
has found it difficult to escape the shadow of her past. As Sarah navigates
adulthood, the chronic stress she experienced in childhood continues to impact
her daily life. She often finds herself feeling overwhelmed by the demands of
work and family responsibilities. Despite her best efforts to cope, Sarah
frequently experiences symptoms of anxiety and depression, which further
compound her stress levels. Over time, the chronic stress takes a toll on Sarah's
physical health as well. She begins to experience frequent headaches, digestive
issues, and insomnia. Despite seeking medical treatment for these symptoms,
Sarah's health continues to deteriorate, and she is diagnosed with a variety of
secondary disorders, including hypertension, irritable bowel syndrome (IBS), and
sleep disorders.

7. Guidelines for the use of different antidepressant
medication.
•The guidelines for the use of antidepressant medications involve
various considerations, including the type of antidepressant, patient
characteristics, and potential side effects.
•It's important to note that these guidelines are general and may be
adjusted based on individual patient needs.

8. When considering the use of antidepressant medication, it's crucial to follow evidence-based guidelines and
individualize treatment based on the patient's specific symptoms, medical history, and preferences.
•Selective Serotonin Reuptake Inhibitors (SSRIs):
•SSRIs are often considered first-line treatment for depression due to their
favorable side effect profile and effectiveness.
•Common SSRIs include fluoxetine (Prozac), sertraline (Zoloft), escitalopram
(Lexapro), and paroxetine (Paxil).
•They are suitable for patients with mild to moderate depression and may also
be effective for severe depression when used in combination with other
treatments.
•SSRIs should be titrated gradually to minimize side effects, and patients
should be monitored for potential adverse reactions such as gastrointestinal
disturbances, sexual dysfunction, and serotonin syndrome.
When considering the use of antidepressant medication, it's crucial to follow evidence-based guidelines and
individualize treatment based on the patient's specific symptoms, medical history, and preferences.
When considering the use of antidepressant medication, it's crucial to follow evidence-based guidelines and
individualize treatment based on the patient's specific symptoms, medical history, and preferences.
When considering the use of antidepressant medication, it's crucial to follow evidence-based guidelines and
individualize treatment based on the patient's specific symptoms, medical history, and preferences.

9. When considering the use of antidepressant medication, it's crucial to follow evidence-based guidelines and
individualize treatment based on the patient's specific symptoms, medical history, and preferences.
•Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):
•SNRIs, such as venlafaxine (Effexor) and duloxetine (Cymbalta), are another
class of antidepressants commonly used in the treatment of depression.
•SNRIs are particularly helpful for patients with comorbid pain conditions or
those who have not responded adequately to SSRIs.
•Like SSRIs, SNRIs should be initiated at a low dose and titrated upward as
tolerated to minimize side effects. Common side effects include nausea,
headache, and insomnia.

10. When considering the use of antidepressant medication, it's crucial to follow evidence-based guidelines and
individualize treatment based on the patient's specific symptoms, medical history, and preferences.
•Tricyclic Antidepressants (TCAs):
•TCAs, such as amitriptyline and nortriptyline, are older antidepressants with
a broader range of side effects compared to SSRIs and SNRIs.
•They are typically reserved for patients who have not responded to or
cannot tolerate newer antidepressants.
•TCAs require careful dosing and monitoring due to their potential for cardiac
toxicity, anticholinergic effects, and sedation.

11. Tricyclic Antidepressants (TCAs):
•Anticholinergic Effects:
•TCAs have a significant affinity for muscarinic acetylcholine receptors, leading to anticholinergic effects. These
effects can include:
•Dry mouth
•Blurred vision
•Constipation
•Urinary retention
•Confusion
•Memory impairment
•Delirium (particularly in elderly patients)
•These side effects can be particularly troublesome for older adults, as they are more susceptible to
anticholinergic toxicity.
•Cardiac Toxicity:
•TCAs have a quinidine-like effect on the heart, which can lead to various cardiovascular effects, including:
•QT interval prolongation on electrocardiogram (ECG)
•Tachycardia
•Arrhythmias (e.g., ventricular tachycardia, torsadesde pointes)
•Myocardial depression
•These cardiac effects can be particularly concerning in patients with preexisting cardiovascular conditions or
those taking other medications that prolong the QT interval or affect cardiac conduction.

12. When considering the use of antidepressant medication, it's crucial to follow evidence-based guidelines and
individualize treatment based on the patient's specific symptoms, medical history, and preferences.
•Monoamine Oxidase Inhibitors (MAOIs):
•MAOIs, such as phenelzineand tranylcypromine, are rarely used as first-line
treatments due to their significant dietary and drug interaction restrictions.
•They may be considered for patients with treatment-resistant depression or
those who cannot tolerate other antidepressants.
•Patients prescribed MAOIs must adhere to strict dietary restrictions to avoid
potentially dangerous interactions with foods containing tyramine.

13. Monoamine Oxidase Inhibitors (MAOIs):
•Dietary Restrictions:
•MAOIs inhibit the activity of the enzyme monoamine oxidase, which breaks down certain neurotransmitters such as
serotonin, dopamine, and norepinephrine. However, they also inhibit the breakdown of tyramine, an amino acid found in
many foods.
•Consuming foods high in tyramine while taking MAOIs can lead to a sudden and dangerous increase in blood pressure,
known as a hypertensive crisis. Foods to avoid include aged cheeses, cured meats, fermented foods, certain fruits (e.g.,
bananas, avocados), and alcoholic beverages.
•Adhering to these dietary restrictions can be challenging and may limit food choices for patients, which can impact their
quality of life.
•Drug Interactions:
•MAOIs can interact with a wide range of medications, including over-the-counter cold and cough medications, certain
antidepressants, decongestants, and even some herbal supplements.
•These interactions can lead to potentially life-threatening serotonin syndrome, hypertensive crisis, or severe central nervous
system effects.
•Due to the risk of dangerous drug interactions, patients taking MAOIs must undergo a thorough medication review, and
healthcare providers must be vigilant in monitoring for potential interactions.
•Risk of Hypertensive Crisis:
•Hypertensive crisis is a severe and potentially life-threatening condition characterized by a sudden and severe increase in
blood pressure.
•While dietary restrictions and drug interactions can contribute to hypertensive crisis, it can also occur spontaneously,
especially at higher doses of MAOIs or when patients are noncompliant with their medication regimen.

14. When considering the use of antidepressant medication, it's crucial to follow evidence-based guidelines and
individualize treatment based on the patient's specific symptoms, medical history, and preferences.
•Atypical Antidepressants:
•Atypical antidepressants include medications such as bupropion (Wellbutrin)
and mirtazapine (Remeron).
•These medications may be considered when patients experience intolerable
side effects with other antidepressants or have specific symptom profiles.
•Bupropion is particularly useful for patients with atypical depression or those
concerned about sexual side effects, while mirtazapine is often prescribed for
patients with insomnia or poor appetite.

15. Atypical depression is a subtype of major depressive disorder characterized by
specific features that distinguish it from other forms of depression. Here are
the key characteristics of atypical depression:
•Mood Reactivity: Individuals with atypical depression typically experience mood reactivity,
meaning their mood improves in response to positive events or situations, even if temporarily.
•Increased Appetite or Weight Gain: Unlike classic depression, where appetite and weight may
decrease, individuals with atypical depression often experience an increase in appetite or
significant weight gain, particularly craving for carbohydrates.
•Hypersomnia: Atypical depression is associated with excessive sleepiness or prolonged sleep,
often including long nighttime sleep periods along with daytime napping.
•Leaden Paralysis: Some individuals with atypical depression report a sensation of heaviness or
paralysis in their arms or legs, which can feel like being weighed down by heavy limbs.
•Rejection Sensitivity: Individuals with atypical depression may be particularly sensitive to
interpersonal rejection or criticism, often experiencing intense distress in response to perceived
social slights.
•Chronic Course: Atypical depression tends to have a chronic or long-standing course, with
symptoms persisting over a period of years rather than resolving quickly.

16. When considering the use of antidepressant medication, it's crucial to follow evidence-based guidelines and
individualize treatment based on the patient's specific symptoms, medical history, and preferences.
•Augmentation and Combination Strategies:
•For patients who do not achieve an adequate response to monotherapy,
augmentation or combination strategies may be considered.
•This may involve adding a second medication, such as an antipsychotic or
lithium, to enhance efficacy.
•Electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS)
may also be options for patients with treatment-resistant depression.
•Augmentation therapy is defined asthe addition of a second agent to an existing
antidepressant regimen with the aim of achieving improved clinical response.

18. Thyroid swelling, also known as goiter, is typically associated with thyroid disorders such as
hypothyroidism (underactive thyroid), hyperthyroidism (overactive thyroid), or thyroid nodules. While
thyroid disorders themselves can contribute to symptoms that may mimic depression or anxiety, such
as fatigue, mood changes, and difficulty concentrating, thyroid swelling alone is not typically
considered a direct indicator of depression.
•However, it's essential to recognize that thyroid disorders and depression can coexist and
sometimes influence each other. For example:
•Impact on Mood and Cognitive Function: Thyroid disorders, particularly hypothyroidism, can lead
to symptoms such as fatigue, low energy, irritability, and cognitive impairment, which may be
mistaken for or exacerbate symptoms of depression.
•Increased Risk: There is evidence to suggest that individuals with thyroid disorders, especially
untreated or inadequately treated hypothyroidism, may have a higher risk of developing
depression or other mood disorders.
•Complex Interaction: The relationship between thyroid disorders and depression is complex and
bidirectional. Depression can also affect thyroid function through mechanisms such as stress-
induced alterations in thyroid hormone levels and hypothalamic-pituitary-thyroid axis
dysfunction.
•Medical Evaluation: If someone with thyroid swelling or known thyroid disorders experiences
symptoms of depression, it's essential for them to undergo a comprehensive medical evaluation
to assess thyroid function and rule out other potential causes of mood disturbances.

19. Some of the physical illnesses commonly
associated with depression

20. Medications known to cause depression

21. Why and how does certain medications cause
depression
•Neurotransmitter Disruption: Some medications can alter the balance of
neurotransmitters in the brain, such as serotonin, dopamine, and
norepinephrine, which are involved in mood regulation. For example, certain
antihypertensive medications, such as beta-blockers and clonidine, can reduce
norepinephrine activity, leading to symptoms of depression in some individuals.
•Hormonal Changes: Hormonal changes induced by medications can also impact
mood. For instance, hormonal contraceptives (birth control pills), hormone
replacement therapy (HRT), and corticosteroids can affect hormone levels and
neurotransmitter activity,potentially leading to mood changes and depressive
symptoms.
•Withdrawal Effects: Abrupt discontinuation or tapering of certain medications
can trigger withdrawal symptoms, including mood disturbances such as
depression or anxiety. This is commonly observed with medications that affect
the central nervous system, such as benzodiazepines, opioids, and certain
antidepressants.

22. Why and how does certain medications cause
depression
•Central Nervous System Effects: Some medications have direct effects on
brain function, which can influence mood and behavior.For example,
isotretinoin(Accutane), a medication used to treat severe acne, has been
associated with mood changes, including depression and suicidal ideation,
possibly due to its effects on neurotransmitter levels and neuroplasticity.
•Genetic Factors: Genetic variations can influence an individual's
susceptibility to medication-induced mood changes. Some people may be
more vulnerable to developing depression in response to certain
medications due to their genetic makeup and how their bodies
metabolize drugs.
•Underlying Conditions: In some cases, medications prescribed to treat
physical health conditions can indirectly contribute to depression by
exacerbating symptoms of the underlying illness or by causing side effects
that impact mood and quality of life.

23. FORMULATING A
TREATMENT
PLAN

24. EVALUATE THE SAFETY OF PATIENT AND OTHERS
•A careful assessment of the patient's risk for suicide should be done.
•During history inquiry for the presence of suicidal ideation and other associated factors
like presence of psychotic symptoms, severe anxiety, panic attacks and alcohol or
substance abuse which increases the risk of suicide need to be evaluated.
•Patients also need to be asked about suicide in their family history.
•During the mental status examinations besides enquiring about the suicidal ideations, it
is also important to enquire about the degree to which the patient intends to act on the
suicidal ideation and the extent to which the patient has made plans or begun to
prepare for suicide.
•The availability of means for suicide be inquired about and a judgment may be made
concerning the lethality of those means.
•Patients who are found to possess suicidal or homicidal ideation, intention or plans
require close monitoring.
•Measures such as hospitalizationmay be considered for those at significant risk.

25. CHOICE OF TREATMENT SETTINGS
•Majority of the cases of depression seen in the clinical setting are of
mild to moderate severity and can be managed at the outpatient
setting.
•In general, the rule of thumb is that the patients may be treated in
the setting that is most safe and effective.
•Severely ill patients who lack adequate social support outside of a
hospital setting may be considered for admission to a hospital
whenever feasible.
•The optimal treatment setting and the patient's ability to benefit from
a different level of care may be re-evaluated on an ongoing basis
throughout the course of treatment.

26. Some indications for inpatient care during
acute episodes

27. Measures which can improve medication
compliance

29. Factors that determine the selection of
Antidepressant Drug

30. Dose and duration of antidepressants
•Patients who have started taking an antidepressant medication should be
carefully monitored to assess the response to pharmacotherapy as well
as the emergence of side effects and safety.
•Factors to consider when determining the frequency of monitoring include
severity of illness, patient's co-operation with treatment, the availability
of social support and the presence of comorbid general medical
problems.
•Visits may be kept frequent enough to monitor and address suicidality and
to promote treatment adherence.
•Improvement with pharmacotherapy can be observed after 4-6 weeks of
treatment.
•If at least a moderate improvement is not observed in this time period,
reappraisal and adjustment of the pharmacotherapy should be considered.

31. Psychotherapeutic interventions
•A specific, effective psychotherapy may be considered as an initial
treatment modality for patients with mild to moderate depressive
disorder.
•Clinical features that may suggest the use of a specific psychotherapy
include the presence of significant psychosocial stressors, intrapsychic
conflict and interpersonal difficulties.
•Patient's preference for psychotherapeutic approaches is an
important factor that may be considered in the decision to use
psychotherapy as the initial treatment modality.
•Pregnancy, lactation, or the wish to become pregnant may also be an
indication for psychotherapy as an initial treatment.

32. Psychotherapeutic interventions for
Depression

33. Basic components of Psycho-education

34. •PHASES OF ILLNESS/TREATMENT
•Management of depression can be broadly divided into three phases, i.e.,
acute phase, continuation phase and maintenance phase.
•Maintenance phase of treatment is usually considered when patient has
recurrent depressive disorder.
•ACUTE PHASE TREATMENT
•The goal of acute phase treatment is to achieve remission, as presence of
residual symptoms increase the risk of chronic depression, poor quality of life
and also impairs recovery from physical illness.
•Treatment generally results in improvement in quality of life and better
functional capacity.

35. Management in the acute phase

36. Treatment
algorithm of
mild to
moderate
Depression

37. Treatment
algorithm of
Severe
Depression

38. 1. Selective Serotonin Reuptake Inhibitors (SSRIs):
•Examples:Fluoxetine, sertraline, paroxetine.
•Guidelines:
•First-line treatment for most types of depression.
•Start with a low dose and titrate gradually.
•Monitor for side effects such as gastrointestinal upset, insomnia, and sexual
dysfunction.
•Caution in patients with a history of bleeding disorders due to potential
increased bleeding risk.

39. 2. Serotonin-Norepinephrine Reuptake Inhibitors
(SNRIs):
•Examples:Venlafaxine, duloxetine.
•Guidelines:
•Useful for patients with comorbid pain conditions or those who have not
responded adequately to SSRIs.
•Monitor blood pressure, especially at higher doses, due to the potential for
increased blood pressure.
•Consider tapering gradually to avoid discontinuation syndrome.

40. 3. Tricyclic Antidepressants (TCAs):
•Examples:Amitriptyline, nortriptyline.
•Guidelines:
•Second-line due to side effect profile and potential for overdose.
•Monitor for anticholinergic effects (dry mouth, constipation, blurred vision).
•Caution in patients with cardiac conditions due to potential QT prolongation.

41. 4. Monoamine Oxidase Inhibitors (MAOIs):
•Examples:Phenelzine, tranylcypromine.
•Guidelines:
•Reserved for treatment-resistant depression due to dietary restrictions and
potential drug interactions.
•Monitor blood pressure regularly, as MAOIs can cause hypertensive crises.
•Strict adherence to dietary restrictions, particularly avoiding tyramine-
containing foods.

42. 5. Atypical Antidepressants:
•Examples:Bupropion, mirtazapine.
•Guidelines:
•Bupropion is less likely to cause sexual dysfunction and may be chosen for
patients with that concern.
•Monitor for seizure risk, especially in patients with a history of seizures (more
relevant for bupropion).
•Mirtazapine may be considered in patients with significant weight loss or
insomnia.

43. 6. Augmentation and Combination Strategies:
•Guidelines:
•Augmentation with lithium or atypical antipsychotics (e.g., quetiapine) can be
considered for treatment-resistant depression.
•Combination therapy (e.g., an SSRI with bupropion) may be utilized based on
individual patient needs.

44. 7. Special Populations:
•Pregnancy and Lactation:
•SSRIs are generally considered safer options, but risks and benefits should be
weighed.
•TCAs may be considered if a patient has responded well in the past.
•Pediatric and Adolescent Patients:
•SSRIs are often the first choice, but close monitoring for suicidality is
essential.
•Fluoxetine is the only FDA-approved SSRI for pediatric depression.

45. General Monitoring and Education:
•Regular Follow-up:
•Schedule regular follow-up visits to monitor response and side effects.
•Suicidality:
•Assess and monitor for suicidality, especially in the early stages of treatment.
•Patient Education:
•Inform patients about the delayed onset of action (usually 2-4 weeks).
•Emphasize the importance of adherence to the prescribed medication regimen.
•These guidelines are broad and should be individualized based on the
patient's clinical presentation, comorbidities, and treatment response.
Close collaboration with mental health professionals is crucial in the
management of depression.

46. PACK Guidelines
•Page 145