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Depression Medical ManagementAka: Medical Management of Depression

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  1. See Also
    1. Depression Management Special Circumstances
  2. General
    1. Providers tend to under dose depression
      1. Refractory Depression may simply need higher levels
    2. Duration of therapy after remission of symptoms
      1. Young: 6 months minimum treatment
      2. Elderly: 2 years minimum use
      3. Rebound Depression off medication: Indefinite use
        1. Continued use reduces relapse risk by two thirds
        2. Geddes (2003) Lancet 361:653
  3. Protocol
    1. Choosing an Antidepressant
      1. Consider Antidepressant Adverse Effects
      2. Consider Depression Types (see below)
        1. Anxious or agitated
        2. Inhibited or withdrawn
      3. Consider effect on sexual function (see below)
      4. Start with generic agents if possible
    2. Choosing a dosage
      1. Many patients are not on the optimal dose
        1. Write prescription to allow patient to increase
      2. Start at sub-therapeutic dose to reduce side effects
      3. Increase dose to minimum effective dose in 5-7 days
      4. Allow patient to increase dose again in 2-3 weeks
      5. Example: Celexa 20 mg (write for 60 with refills)
        1. Start at 1/2 tablet daily for 5-7 days
        2. Then increase to 1 pill daily for 2-3 weeks
        3. Then consider increase to 2 pills daily
  4. Management: Generic agents
    1. First choice
      1. Citalopram (Celexa)
      2. Sertraline (Zoloft)
      3. Buproprion (Wellbutrin)
    2. Second choice (due to side effects)
      1. Fluoxetine (Prozac): Activating
      2. Paroxetine (Paxil): Sedating and withdrawal risk
      3. Mirtazapine (Remeron): Sedating and weight gain
        1. Elderly may see side effects as helpful
    3. References
      1. Goad (2007) Chronic Disease Lecture, MPLS
  5. Management: Anxiety, Agitation or Insomnia
    1. Use Sedating Antidepressant
      1. Paroxetine (Paxil)
      2. Nefazodone (Serzone)
      3. Mirtazapine (Remeron)
    2. Consider medication to assist sleep
      1. Trazodone (Desyrel) 25-50 mg PO qhs
    3. Consider Benzodiazepine for first 1-2 weeks
      1. Clonazepam
  6. Management: Psychotic Depression
    1. See Depression with Psychotic Features Management
  7. Management: Inhibited Depression
    1. First Line: SSRI
      1. Fluoxetine (Prozac)
      2. Bupropion (Wellbutrin)
    2. Second Line: Tricyclic Antidepressant
      1. Imipramine (Tofranil)
      2. Desipramine (Norpramin)
      3. Protriptyline (Vivactil)
  8. Management: Sexual dysfunction
    1. See Antidepressant Induced Sexual Dysfunction
    2. Man with Premature Ejaculation: Paxil
    3. Woman lacks orgasm: Buspar 30 minutes prior to sex
    4. Agents least likely to affect sexual function
      1. Nefazodone (Serzone)
      2. Bupropion (Wellbutrin)
      3. Mirtazapine (Remeron)
      4. Citalopram (Celexa)
      5. Fluvoxamine (Luvox)
  9. Management: Perimenopausal Major Depression
    1. Estrogen Replacement effective as Antidepressant
      1. Soares (2001) Arch Gen Psychiatry 58:529
  10. Management: Depression Refractory to Antidepressants
    1. See Refractory Depression Management

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