Drug Selection Table for Schizophreniform Disorders
Chapter 11 Chapter 11
1. SIG E CAPS Depressed mood
Decreased sleep (insomnia with 2 a.m. to 4 a.m. awakening)
Interest decreased in activities (anhedonia)
Guilt or worthlessness (not a major criterion)
Energy decreased
Concentration difficulties
MajOR DEpRESSIvE DISORDER (MDD) 147
Appetite disturbance or weight loss
Psychomotor retardation/agitation
Suicidal thoughts
2. Beck Depression Inventory: 21-question survey completed by patient
3. Zung Self-Rating Scale: 20-question survey completed by patient, Likert-type scale format
4. PHQ-9: The Patient Health Questionnaire, a brief survey completed by patient Past medical history
Family medical history, with emphasis on psychiatric history
Social history, including safety of relationships, family support, recent or ongoing
stressors
Past suicide attempts or past psychiatric hospitalizations
Any prior manic/hypomanic episodes (
any history suggests bipolar or cyclothymia
diagnosis); Mood Disorder Questionnaire is a helpful tool
What effect symptoms have had on ability to function (any missed work, etc.)?
Assess for suicide ideation, suicide plan, and suicide intent
Clinical presentation
Somatization: often, presentation of depression is through complaints of (often
multiple) physical symptoms that do not have clearly identifiable causes Sadness
Lack of enjoyment of usual activities (anhedonia)
Fatigue
Sleep problems (early-morning awakening with difficulty or inability to fall back
asleep is typical) Feelings of guilt
Feeling overwhelmed
Difficulty concentrating, focusing, or remembering
Appetite disturbances (lack of appetite, or excessive eating)
Irritability, agitation, or slowed movements
Thoughts of suicide or wanting to “escape”
Obsessive rumination about problems
Signs
Flattened affect
Slowed speech and movements, sighs, long pauses
Tearfulness
Lack of eye contact
Memory loss, poor concentration, or poor abstract reasoning
Sometimes irritability, belligerence, or defiance (more common in adolescence)
DSM-5 Diagnostic Guidelines
Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) distinguishes between MDD—single episode—and MDD—recurrent.
For MDD—single episode:
At least five of the following symptoms have been present for at least 2 weeks in
duration: depressed mood, anhedonia, change in eating habits, sleep disturbance, psychomotor agitation or retardation, fatigue, excessive guilt or feelings of worth- lessness, difficulty concentrating, and recurrent thoughts of death or suicide (at least one of the symptoms being depressed mood or anhedonia).
Symptoms must cause a significant social or occupational dysfunction or subjective
distress.
Symptoms cannot be caused by a medical condition, medications, drugs, or
bereavement.
For MDD—recurrent:
Two or more major depressive episodes (MDEs) occur.
Absence of manic, hypomanic, or “mixed” episodes
TREaTMENT OvERvIEW acute Treatment
Psychotropic medication should be selected based on relative efficacy, tolerability
and anticipated side effects, co-occurring psychiatric or general medical conditions, half-life, cost, potential drug interactions, and the patient’s preference and prior response to medication.
The onset of benefit from pharmacological treatment may be more gradual in MDD
than the onset of benefit in nonchronic depression.
Treatment of nonresponsive patients should be re-evaluated for accuracy of
diagnosis, unaddressed co-occurring medical or psychiatric disorders, such as substance abuse, the need for a change in treatment modalities, inadequate dose or duration of medical treatment, the need to augment medical treatment (with a second antidepressant from a different pharmacological class, or use of an adjunc- tive such as a second-generation atypical antipsychotic, anticonvulsant or thyroid hormone), inadequate frequency of psychotherapy, complicating psychosocial fac- tors, nonadherence to treatment, and poor “fit” between patient and therapist.
Common combinations of medications include a selective serotonin reuptake
inhibitor (SSRI) with the addition of bupropion or the combination of mirtazapine and an SSRI or venlafaxine.
Pharmacotherapy may increase the potential of suicidal ideation, particularly in
patients younger than 25 years of age. General guidelines include:
Patients initiated on any psychiatric medication intervention should be
monitored carefully for changes in mood or suicidal behavior or ideation.
Depressed patients with suicidal ideation, plan, and intent should be hospitalized,
especially if they have current psychosocial stressors and access to lethal means.
Depressed patients with suicidal ideation and a plan but without intent may be
treated on an outpatient basis with close follow-up, especially when they have good social support and no access to lethal means.
Depressed patients who express suicidal ideation but deny a plan should
be assessed carefully for psychosocial stressors. Remove weapons from the environment.
Pay careful attention in the first 1 to 4 weeks of treatment to a sudden lift of
depression or to worsening mood as initial response to antidepressant therapy as these could be signs of increased risk for suicide.
Pharmacotherapy for MDD should begin at the lowest dosage and gradually be
increased, if needed, following a 4-week evaluation for therapeutic response.
Patients should be observed 1 to 2 weeks after initiation of therapy for evaluation of adverse drug effects. Frequency of monitoring should be determined based on symptom severity, co-occurring disorders, availability of social support, patient cooperation with treatment, and side effects of medication.
MajOR DEpRESSIvE DISORDER (MDD) 149
The combination of pharmacological therapy and cognitive behavioral therapy
(CBT), individually or in combination, is effective in more than 85% of cases.
Chronic Treatment
Pharmacotherapy with or without individual counseling, particularly CBT, is the
treatment of choice, and should be considered for patients.
Cognitive restructuring involves substituting positive perceptions for negative
perceptions and assistance with problem solving and stress management.
Once the patient has reached remission of symptoms, the patient is monitored for
an additional 4 to 9 months prior to tapering the medication, or, in the case of three or more episodes, the patient is placed on maintenance treatment.
In cases in which medication loses its effectiveness, alternative regimens and diag-
noses should be explored.
Electroconvulsive therapy (ECT) is recommended as the treatment of choice for
patients with severe MDD that is not responsive to pharmacologic treatment and psychotherapy.
Pharmacologic education should include:
Frequency of dosing
The likelihood that side effects will occur prior to improvement of symptoms
Expectations that it will take 2 to 4 weeks prior to beneficial effects and 4 to 8
weeks prior to full effects of the dosage
The importance of taking medication even after feeling better
Consulting with the health care provider before discontinuing medication
Correcting misconceptions about medication use, and explaining what to do if
side effects, questions, or worsening symptoms arise.
Nonpharmacologic recommendations should also be made such as:
Proper sleep hygiene
Decreased use or elimination of caffeine, tobacco, and alcohol
Light therapy
Regular exercise.
Consider long-term treatment in patients with two or more episodes. A history of
three or more episodes of depression indicates a very high risk for recurrence and the need for continuous treatment.
Also may increase the risk of bleeding for patients on NSAIDs/ASA and anticoagu-
lation therapy.
Stress management and lifestyle changes, such as regular exercise, which have been
found to decrease depression, are essential for ongoing prevention.
Behavioral therapy involves various relaxation techniques, self-care strategies, and
cognitive and dialectical therapy may also be helpful. Studies suggest that augmen- tation of antidepressant effect occurs with adjunct use of omega-3 fish oil supple- ments, 1,000 mg twice daily. B vitamin supplementation has also been used in some studies, with equivocal results.
Treatment can be complicated by having another condition at the same time, such
as substance abuse, depression, or other anxiety disorders.
NOTES ON SSRIs aS FIRST LINE OF DRUG THERapY
SSRIs are one of the more commonly used medications for MDD.
SSRI medications typically display fewer side effects than tricyclic antidepressants
(TCAs) and monoamine oxidase inhibitors (MAOIs), with minimal risk of death in
an intentional overdose. Treatment decisions should take into consideration patient symptoms and medication side effect profile.
They also may increase the risk of bleeding for patients on NSAIDs/ASA and anti-
coagulation therapy.
SSRI medications may not be preferred for patients with sexual dysfunction or who
find sexual dysfunction as an intolerable side effect.
Limited or no cholinergic, histaminergic, dopaminergic, or adrenergic receptor
activity (i.e., they do not cause hypotension or anticholinergic response) May be of benefit to perimenopausal women experiencing hot flashes
Patients reporting intolerable side effects from one SSRI may benefit from switch-
ing to another SSRI.
SSRIs inhibit serotonin 2A receptors and serotonin reuptake
Receptor inhibition produces a sedating effect.