CLINICAL MANAGEMENT GUIDELINE

Major depressive disorder

ICD10: Major depressv disord, single epsd, sev w/o psych features [F32.2]

Treatment: Pharmacological and Cognitive therapy

Defintion: It is a mood disorder characterized loss of interest and low mood, see DSM-5 criteria.

It thoughts to be caused by abnormality of neurotransmitters' concentrations of the hypothalamic-pituitary-adrenal (HPA) axis.

Role play


Diagnostic Criteria: at least ≥ 5 symptoms X 2 weeks. Depressed mood or/and reduced interest must be positive to diagnose major depression as per DSM-5 diagnostic criteria.

1. Depressed mood; most of the day and almost every day. Sadness, emptiness, hopelessness, or tearfulness are more common.

2. Reduced interest; most of the day and almost every day.

  1. Significant (5%) weight loss/gain, unintentionally.

  2. Insomnia or hypersomnia; most of the day and almost every day.

  3. Psychomotor agitation (restless) or retardation (Slow); observed by others.

  4. Fatigue; most of the day and almost every day.

  5. Feeling guilt and worthlessness.

  6. Low ability to concentrate and think; most of the day and almost every day.

  7. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan.

Preconditions:

  1. It must cause functional impairment (e.g., social, occupational).

  2. Substance abuse, medication side effects, or other psychiatric or somatic medical conditions should be excluded.

    thyroid function tests, metabolic panel, full blood count, serum vitamin B12 and folate levels, and 24-hour urinary cortisol may also be informative.

  3. Mania or hypomania history should be excluded.


Investigation:

For excluding other etiologies and intiate labartory base line.

  • Metabolic panel.
  • CBC.
  • TFT.
  • LFTs
  • 24 - hr urine free cortisol.
  • B 12 vitamin, to exclude deficiency; which associates w/ impare memory (rare).

DDx:

  • Bipolar.
  • Hypomania.
  • Griefing.
  • demntia.
  • hypothyroidisim.
  • Medication-relater; corticoids, interferon, levodopa, propranolol, and oral contraceptives.
  • B12 deficancy.

PMID: 12451082, ,

DSM–5,


Clinical goals:

Symptoms eradication, retain normal functional/profissional lifestyle, reduce suicide risk, control medications adverse events, and maintain remission.

Choosing the appropriate antidepressant should be tailored to your patient's preference to the adverse effects profile, cost, insurance coverage, etc. 1


How to monitor:

If the patient does not "respond" after 1-2 weeks of starting your medication trial,

titer up the dose gradually as per instructions. After 2-4 weeks, if the patient still doesn't respond at higher doses, Change to alternative pharmacological class. After trying >2 different pharmacological classes on full doses and duration, Consider the patient as resistant and refer to a specialist.


Monitoring tools:

PHQ-9 questionnaire

Outcomes:

Response: improvement ≥50 percent in comparison to the previous score but less than the threshold for remission, i.e., <5.

Remission: score <5.


Be alert If patient manifests psychotic signs; hallucinations or paranoia, suicidal, catatonic or psychomotor retardation impeding activities; use GROA's management plan for anti psychosis.

Be alert to the increased risk of suicide in the first weeks of high-does of antidepressants, especially in young patients. 2


Management:

1st line:

Psychotherapy:

it has a positive impact on the quality of life of patients with depression. It helps to achieve remission in 41% of patients vs 21% in the control group.468

And

Pharmacology: 10, 11, 12, 13, 14, 15

SSRIs:

Sertraline 25- 300 mg, PO, divided on OD-TID, continue for 6-12 months after remission to reduce the risk of relapse.

Increment by 10 mg after > 7 days interval. If taken >3 weeks, and need to D/C, gradually taper the dose over 1 to 4 weeks; to reduce withdrawal AE.

Adverse effect:Frequency
Sexual dysfunction (ejaculation)▂▃▅▆
Diarrhea, transient▂▃▅
Insomnia▂▃▅
Orthostatic hypotension▂▃
Weight gain▂▃
QTc prolongation

escitalopram 5- 30 mg, PO, OD, continue for 6-12 months after remission to reduce the risk of relapse.

Increment by 10 mg after > 7 days interval. If taken > 3 weeks, and need to D/C, gradually taper the dose over 1 to 4 weeks; to reduce withdrawal AE.

Adverse effect:Frequency
Sexual dysfunction (ejaculation/impotence, libido)▂▃▅▆
GIT, transient (diarrhea, nausea)▂▃
Insomnia▂▃
Orthostatic hypotension▂▃
Weight gain▂▃
QTc prolongation▂▃

fluoxetine 10-80 mg, PO, OD, continue for 6-12 months after remission to reduce the risk of relapse.

Increment by 10 mg after > 7 days interval. If taken > 3 weeks, and need to D/C, gradually taper the dose over 1 to 4 weeks; to reduce withdrawal AE.

Adverse effect:Frequency
Sexual dysfunction▂▃▅▆
GIT adverse events▂▃
Insomnia▂▃▅
Orthostatic hypotension▂▃
Weight gain▂▃
QTc prolongation▂▃

SNRIs:

Venlafaxine extended-release 37.5- 375, PO, OD, continue for 6-12 months after remission to reduce the risk of relapse.

Increment after > 7 days interval. If taken > 3 weeks, and need to D/C, gradually taper the dose over 1 to 4 weeks; to reduce withdrawal AE. Administering with food to reduce nausea.

Adverse effect:Frequency
Sexual dysfunction▂▃▅▆
GIT adverse events, transient▂▃▅
Insomnia▂▃
Orthostatic hypotension
Weight gain
QTc prolongation▂▃
Anticholinergic,(dry mouth, constipation, etc)

Duloxetine 15-60 mg, PO, BID, continue for 6-12 months after remission to reduce the risk of relapse.

Increment by 10-20 mg after > 7 days interval. If taken > 3 weeks, and need to D/C, gradually taper the dose over 1 to 4 weeks; to reduce withdrawal AE. Administering with food to reduce nausea.

Adverse effect:Frequency
Sexual dysfunction▂▃
GIT adverse events, transient▂▃▅
Insomnia▂▃
Orthostatic hypotension
Weight gain
QTc prolongation
Anticholinergic,(dry mouth, constipation, etc)

Atypicals:

Bupropion 12-Hr release 100-200, PO, divide for OD-BID, continue for 6-12 months after remission to reduce risk of relapse.

Increment by 10-20 mg after > 7 days interval. If taken > 3 weeks, and need to D/C, gradually taper the dose over 1 to 4 weeks; to reduce withdrawal AE.

Adverse effect:Frequency
Sexual dysfunction
GIT adverse events, transient▂▃▅
Insomnia▂▃
Orthostatic hypotension
Weight gain
QTc prolongation▂▃
Anticholinergic,(dry mouth, constipation, etc)

Mirtazapine 15-45 mg, PO, OD at bet-time, continue for 6-12 months after remission to reduce the risk of relapse.

Increment by 10-20 mg after > 7 days interval. If taken > 3 weeks, and need to D/C, gradually taper the dose over 1 to 4 weeks; to reduce withdrawal AE.

Adverse effect:Frequency
Sexual dysfunction▂▃
GIT adverse events, transient
Insomnia
Orthostatic hypotension
Weight gain▂▃▅▆▇
QTc prolongation▂▃
Anticholinergic,(dry mouth, constipation, etc)▂▃
Drowsiness▂▃▅▆▇

Serotonin modulators:

Trazodone 50 - 300 mg, PO, BID, continue for 6-12 months after remission to reduce the risk of relapse.

Increment by 50 mg, BID after > week interval, and as per response.

If dose exceeded 300 mg/ day, increment at 2-4 weeks interval.

If taken > 3 weeks, and need to D/C, gradually taper the dose over 1 to 4 weeks; to reduce withdrawal AE.

On high doses, you should frequently monitor for AEs.

Adverse effect:Frequency
Sexual dysfunction, caution for priapism(rare)▂▃
GIT adverse events, transient▂▃▅▆
Insomnia
Orthostatic hypotension▂▃▅▆
Weight gain▂▃
QTc prolongation▂▃▅
Anticholinergic,(dry mouth, constipation, etc)
Drowsiness▂▃▅▆▇

Vortioxetine 10-20 mg, PO, OD, continue for 6-12 months after remission to reduce the risk of relapse.

Increment by 10mg, OD at > week interval as per response.

If taken > 3 weeks, and need to D/C, gradually taper the dose over 1 to 4 weeks; to reduce withdrawal AE.

Adverse effect:Frequency
Sexual dysfunction, caution for priapism(rare)▂▃
GIT adverse events, transient▂▃▅▆
Insomnia
Orthostatic hypotension
Weight gain
QTc prolongation
Anticholinergic,(dry mouth, constipation, etc)
Drowsiness

Switching between medications:

  1. Dose overlapping method for non-sever drug interaction:

    Over 1-4 weeks (based on patient response), reduce the current drug while starting at low dose & titer up the new drug until equivalent strength equalize, then withdraw.

Treatments

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