Depression and Anxiety Management for Healthcare Providers

Depression

Step 1: Rule Out Medical Causes

Does the patient have any of the following symptoms?

  • Low Mood
  • Irritability
  • Fatigue/tiredness
  • Concentration problems
  • Memory problems
  • Sleep disturbances (insomnia/excessive sleep)
  • Dizziness
  • Weakness
  • Anxiety
  • Unexplained weight changes

 

If Yes, rule out common medical problems

Differential DiagnosisComments
Alcohol/Substance Use DisordersAlcohol, Opiates/Opioids, Benzodiazepines, Stimulants
Adjustment Disorders; BereavementAdjusting to new medical diagosis or recent stressors.
Other Psychiatric Disorders Anxiety Disorders, Bipolar Disorder, Psychotic Disorders, Premenstrual Dysphoria
Eating DisordersMalnutrition
Sleep DisordersObstructive Sleep Apnea (OSA), Narcolepsy, Periodic Limb Movement Disorder, Primary Insomnia
MedicationsCorticosteroids, beta-blockers (propranolol), Interferons, Varenicline, Hormonal Contraceptives, Tamoxifen, Aromatase Inhibitors, Calcium Channel Blockers, Acyclovir, Barbiturates, Topiramate, Digoxin, L-Dopa, Metoclopramide
B12 DeficiencyNeuropathy, Proprioception deficits. Order B12 levels
Iron DeficiencyAnemia work up. Order Fe, Ferritin, Transferrin, TIBC
HypothyroidismConstipation, weight gain, fatigue. Order TSH, T4.
Cushing Disease24hr urinary cortisol, Dexamethasone suppression test.
HIV/AIDS
Cancer
Stroke/Cerebrovascular DiseaseLeft Sided > Right Sided Infarctions
Traumatic Brain Injury
Autoimmune DiseaseLupus, Rheumatoid Arthritis, Multiple Sclerosis, Myasthenia Gravis, Polymyositis
Dementia

Diagnosing Depression

PHQ-9 Tool

The PHQ-9 Tool consists of 9 questions which screen for depression. 

Rule Out Bipolar Disorder

It is important to screen for history of manic or hypomanic episodes. This will decrease the probability of incorrectly diagnosing Unipolar depression. Remember that unipolar and bipolar depression are treated differently.

BE SURE TO SCREEN FOR HISTORY OF MANIA/HYPOMANIA TO RULE OUT BIPOLAR DISORDER

How to Rule out history of manic or hypomanic episodes:

Did the patient have three (3) or more of the following additional symptoms?

  1. Inflated self esteem
  2. Decrease need for sleep (e.g. feels rested after only 3 hours of sleep)
  3. More talkative than usual or pressure to keep talking
  4. Flight of ideas or racing thoughts
  5. Increased goal-directed activities (socially, work related, school, sexual) or agitation 
  6. Easily distracted
  7. High risk behaviors/activities (e.g., speeding, buying sprees, sexual indiscretions, foolish business investments)

IF NO, UNLIKELY BIPOLAR DEPRESSION

IF YES, LIKELY BIPOLAR DEPRESSION AND CONSIDER THE FOLLOWING:

 

Treatment of Bipolar Depression

Pharmacotherapy For Bipolar DepressionMonotherapyCombination Therapy
First-LineLithiumLithium + Bupropion
Lithium + Valproic Acid
Lamotrigine Lamotrigine + Lithium
Lamotrigine + Quetiapine
Atypical Antipsychotic: Quetiapine, LurasidoneValproic Acid + Bupropion
Olanzapine + Fluoxetine
Second-LineValproic AcidLithium + Valproic Acid
Carbamazepine

Treatment Algorithm for Unipolar Depression

How to Choose an Antidepressant

Clinical trials typically exclude patients with complex medical or psychiatric histories. This makes choosing medications very difficult for these patients. Choosing an antidepressant often comes down to a combination of factors including individual symptoms, antidepressant side effects, and comorbid medical or psychiatric conditions.

Important Points

  • Antidepressant medications are generally safe but can be problematic in patients with complex medical conditions or in those patients taking multiple medications with potential drug interactions.
  • The information provided here or anywhere on this website is for educational purposes only. Patients are individuals and these general recommendations do not apply to all patients.
  • Thoughtful clinical judgment taking into account each patient’s unique and complex history will always carry more weight than any general approach or guide.

Symptom-Based Method

Anxiety, Insomnia, Anorexia

  • Paroxetine (Paxil)
  • Sertraline (Zoloft)
  • Mirtazapine (Remeron)
  • Trazodone (Desyrel)
  • Buspirone (Buspar)
  • Amitriptyline
  • Nortriptyline 
  • Lithium (As augmentation)

Anhedonia, Fatigue, Concentration problems, Motivation Problems

  • Bupropion (Wellbutrin)
  • Fluoxetine (Prozac)
  • Sertraline (Zoloft)
  • Venlafaxine (Effexor)
  • Desvenlafaxine (Pristiq)
  • Duloxetine (Cymbalta)
  • Selegiline
  • Thyroid Hormone (as augmentation)

Ruminations/Obsessions

  • Sertraline (Zoloft)
  • Fluoxetine (Prozac)
  • Paroxetine (Paxil)
  • Fluvoxamine (Luvox)
  • Citalopram (Celexa)
  • Escitalopram (Lexapro)
  • Venlafaxine (Effexor)
  • Clomipramine (Anafranil)

Pain

  • Duloxetine (Cymbalta)
  • Venlafaxine (Effexor)
  • Desvenlafaxine (Pristiq)
  • Nortriptyline
  • Amitriptyline 

Comorbidity-Based Method

Liver Disease

Adjust dose according to Child Pugh Score (see below):

  • Score A (5-6 points): 75-100% regular dose
  • Score B (7-9 points): 50% regular dose
  • Score C (10-15 points): CAUTION/AVOID USE

ParameterAbsent (1 point)Slight (2 points)Moderate (3 points)
Bilirubin (mg/dL)<22 to 3>3
Albumin (g/dL)>3.52.8-3.5<2.8
Prothrombin Time (seconds over control)<42021-04-06 00:00:00>6
INR<1.71.7-2.3>2.3
EncephalopathyNoneMild to ModerateSevere

Preferred Antidepressants:

  • Sertraline (Zoloft)
  • Citalopram (Celexa)
  • Escitalopram (Lexapro)
  • Desvenlafaxine (Pristiq)
  • Mirtazapine (Remeron)

Try to avoid:

  • Duloxetine (Cymbalta)
  • Venlafaxine (Effexor)
  • Tricyclic Antidepressants (TCAs)
  • Monoamine Oxidase Inhibitors (MAOIs)
  • Nefazodone

Elevated Transaminases (ALT>AST) seen mostly with

  • TCAs
  • Duloxetine (Cymbalta)
  • Venlafaxine (Effexor)

Cardiovascular Disease

Based on the following studies/trials: MIND-IT Trials, SAD HEART trial, EsDEPACS trial, and CREATE trial

Coronary Artery Disease

  • Sertraline (Zoloft)
  • Mirtazapine (Remeron) 
  • Citalopram (Celexa)
  • Escitalopram (Lexapro) 
  • Nortriptyline (50-150ng/mL): relatively well tolerated in patients with impaired left ventricular dysfunction (Roose and Glassman 1989)

Congestive Heart Failure

  • Paroxetine
  • Mirtazapine
  • Bupropion
  • Venlafaxine
  • Duloxetine (monitor blood pressure)

Increased QTc prolongation Risk associated with

  • Citalopram (Celexa) >40mg / day
  • Escitalopram (Lexapro) >20mg / day
  • Tricyclic Antidepressants
  • Venlafaxine (Effexor)
  • Mirtazapine (Remeron)

Renal Disease

  • All antidepressants may be used in patients with renal failure and end stage renal disease (ESRD)
  • As a general rule, start low and go slow
  • Caution with renally excreted drugs in ESRD (lithium, paroxetine, desvenlafaxine, venlafaxine*)

Antidepressants and effects on Genitourinary (GU) system:

  • SSRIs/SNRIs: SIADH, Polydipsia, Hyponatremia,
  • TCAs: Urinary retention, Urinary hesitancy, SIADH, hyponatremia, psychogenic polydipsia  
  • Duloxetine: Urinary retention

Hemodialysis (HD) Patients

  • Up to 70% of patients older than 55 years old have moderate to severe chronic cognitive impairment
  • Duloxetine is not properly excreted in HD (CNS Toxic)
  • Mirtazapine and Amitriptyline levels ↓ after HD
  • Fluoxetine (and norfluoxetine) levels not affected
  • TCAs have longer elimination half-life in patients on HD
  • Be careful with medications prone to cause orthostasis as HD patients have rapid fluid shifts and are very susceptible to orthostatic hypotension

Rheumatology Disorders

Rheumatoid Arthritis

  • Sertraline
  • Doxepin
  • Paroxetine
  • Amitriptyline
  • Duloxetine
  • Venlafaxine

Osteoarthritis

  • Duloxetine
  • Venlafaxine 
  • Desvenlafaxine

Respiratory Disease

Preferred Antidepressants:

  • Citalopram
  • Sertraline
  • Paroxetine
  • Nortriptyline
  • Desipramine
  • Buspirone (Buspar)

Obstructive Sleep Apnea (OSA)

  • Avoid Mirtazapine (if possible)
  • Avoid TCAs (if possible)
  • Avoid Benzodiazepines (if possible)

Asthma/COPD:

  • Avoid Beta blockers (if possible)

Neurological Disease

Stroke

  • Citalopram
  • Sertraline
  • Fluoxetine
  • Dextroamphetamines
  • Methylphenidate
  • Nortriptyline

Pseudobulbar Affect

  • Citalopram
  • Sertraline
  • Nuedexta

Parkinson’s Disease (PD)

  • Pramipexole
  • Sertraline
  • Escitalopram
  • Citalopram
  • Duloxetine
  • Mirtazapine
  • Donepezil
  • Rivastigmine
  • Selegiline
  • Pimavanserin

Traumatic Brain Injury (TBI)

  • Sertraline
  • Fluoxetine
  • Citalopram
  • Escitalopram
  • Nortriptyline
  • Amitriptyline (post-concussive headache)
  • Methylphenidate
  • Dextroamphetamine
  • Milnacipran

Pregnancy

Preferred Antidepressants during Pregnancy:

  • Sertraline
  • Fluoxetine
  • Citalopram
  • Escitalopram

Antidepressants to Avoid (if possible) during Pregnancy:

  • Paroxetine
  • TCAs
  • MAOIs
  • Mirtazapine

Breastfeeding

Preferred Antidepressants while Breastfeeding:

  • Sertraline
  • Fluoxetine
  • Citalopram
  • Paroxetine

Antidepressant Table

Selective Serotonin Reuptake Inhibitors (SSRIs)Initial Dose (Range), mgComments
Fluoxetine (Prozac)20 (20-60)Activating. Long half-life. 2D6 Inhibitor.
Paroxetine (Paxil)20 (20-60)Anticholinergic. Sedating. 2D6 Inhibitor. Sexual side effects. D/C syndrome. Pregnancy risk.
Sertraline (Zoloft)50 (50-200)Activating. Dopaminergic. 2D6 Inhibitor at higher doses. GI side effects common early in tx.
Citalopram (Celexa)20 (20-60)Few interactions. QT prolongation (>40mg/day).
Escitalopram (Lexapro)10 (10-20)Few interactions. QT prolongation.
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Duloxetine (Cymbalta)30 (30-60)Short half life with risk of d/c symptoms. FDA approved for Diabetic neuropathy and Fibromyalgia. Morning dosing. Rarely sedating. May increase BP.
Venlafaxine XR (Effexor XR)37.5 (75-300)Nausea common. May increase BP. Once daily dosing with XR minimizes side effects (i.e., nausea). Reduce dose in renal insufficiency. May help with chronic pain.
Desvenlafaxine (Pristiq)50 (50-100)Active metabolite of venlafaxine. More noradrenergic activity than venlafaxine. Better choice for those with renal and hepatic insufficiency. May help with chronic pain. Short half-life with risk of d/c symptoms.
Atypical Antidepressants
Bupropion (Wellbutrin)100 (100-400)Noradrenergic and Dopaminergic. Minimal sexual side effects. May increase BP. Avoid in those with eating disorders or seizure hx. 2D6 inhibitor.
SR (BID dosing)150 (150-450)
XL (QAM dosing)
Trazodone (Desyrel)25 (25-400)Sedating. Commonly used for insomnia. May increase time in slow wave sleep. No anticholinergic properties. Histamine/α1 at low doses. Minimal sexual side effects. Warn about priapism. May be better for anxiety than depression.
Mirtazapine (Remeron)7.5 (7.5-45)Noradrenergic and serotonergic properties. Has actions at 5HT3 and therefore helps with nausea. Minimal sexual side effects. Sedation and weight gain common. Sedation usually limited to 7.5mg-15mg.

Additional Information

HEALTH: “A state of complete physical, mental, and social well being, and not merely the absence of disease or infirmity.” – World Health Organization, 1948

Chronic Medical Illness and Depression: A Bidirectional Relationship

Facts

  • Up to 75% of all mental health care is delivered in primary care settings.
  • Primary care providers (PCPs) are usually the first providers a patient encounters
  • Stigma prevents patients from seeking mental health treatment from a mental health provider
  • The shortage of mental health providers increasingly places pressure on Primary Care Providers 
  • There is significant overlap between symptoms of depression and common medical conditions (e.g., pain, fatigue, insomnia, appetite changes).
  • Up to 17% of adults experience one major depressive episode in their lifetime
  • 5%-10% of patients seen in primary care settings meet criteria for major depressive disorder
  • 1 in 4 patients in primary care clinics have sub threshold depression or persistent depressive disorder
  • Untreated depression in medical populations is associated with greater somatic symptom burden, poorer quality of life, and overall worse outcomes
  • Risk for depression increases with number of medical diagnoses
  • Depression is associated with higher rates of health care utilization (Cost of medical care for depressed patients is 50% higher than for non-depressed patients)
  • Depressed patients tend to be less adherent with medical treatment, less productive at work (or unemployed/on leave), and more resistant to medical treatment

Misconceptions

  • Depression is “normal” and “understandable” under certain circumstances and does not require treatment (Depression is not a “normal response” to anything)
  • Normal sadness and depression are the same thing (NOT TRUE)
  • Depression due to acute and/or chronic pain is “understandable” and does not require treatment (NOT TRUE)
  • Pain and other somatic symptoms are uncommon presenting complaints in patients with depression (NOT TRUE)
  • “Antidepressants don’t really work” (NOT TRUE)

 

Anxiety

Anxiety is a nonspecific term and can present in the following ways:

  • Excessive worries, doubts, or fears
  • Immediately thinking about the worst case scenario in any situation 
  • Nervousness
  • Restlessness
  • Feeling “On Edge”
  • Feeling “overly aware” or hyper vigilant
  • Feeling like something bad is going to happen
  • Racing thoughts and Ruminations
  • Insomnia/sleep disturbances

Physical Symptoms:

  • Pain
  • Tingling
  • Numbness
  • Weakness
  • Vision changes
  • Shortness of breath
  • Palpitations/Racing heart beat
  • Chest pain
  • stomach pain/Indigestion
  • Muscle tension and tightness 
  • Headaches

Screening: GAD-7

The GAD-7 is a clinical screening tool used to screen for generalized anxiety disorder (GAD). The GAD-7 consists of seven (7) questions and is provided below:

Medical Work Up

Anxiety can be caused by numerous medical problems. Be sure to rule out medical causes of anxiety before attributing the anxiety to a primary psychiatric disorder. The medical workup for anxiety is provided below.

ConditionWork Up
Cardiac DiseaseElectrocardiogram
Asthma, COPDChest X-Ray; Pulmonary Function Tests
Thyroid DiseaseTSH w/ reflex Free T4
HypoglycemiaMetabolic Panel
PheochromocytomaUrine Testing
AnemiaCBC w/ Differential; Iron Studies (Ferritin, TIBC, Iron, Transferrin)
SeizuresElectroencephalogram (EEG); MRI
Substance Abuse (Stimulants, PCP, MDMA, Cannabis, Nicotine, Caffeine)Urine/Serum Toxicology; Inquire about drug use
Withdrawal States (Alcohol, Benzodiazepines, Opioids)Urine/Serum Toxicology; Inquire about drug use
Medication Side EffectsPseudoephedrine, Methylphenidate, Amphetamines, beta-agonists, Amantadine, Bromocriptine, L-dopa, Bupropion, Antipsychotics, Steroids, Meperidine, Metoclopramide, Oxybutinin, Meperidine, Benztropine, Theophylline, Indomethacin

Anxiety Diagnosis Algorithm

Anxiety Disorders are classified by the presence or absence of triggers or precipitating events that cause anxious symptoms:

  • More than one diagnosis is common
  • Consider referral to Psychiatry if none of the above diagnoses can be identified
  • Medical problems and psychiatric disorders influence each other and both need to be addressed appropriately
  • Anxiety symptoms should be addressed and treated even if they are attributed to a medical condition

 

Anxiety Treatment Options

DisorderFirst-Line Treatment
Generalized Anxiety DisorderSSRI +/- CBT*
Panic DisorderSSRI +/- CBT*
Social Anxiety Disorder (Social Phobia)SSRI +/- CBT
Obsessive Compulsive DisorderSSRI +/- ERP +/- ACT
Acute Stress Disorder/PTSDSSRI +/- CBT +/- PET
*Benzodiazepines may be used in the short term
CBT, Cognitive Behavioral Therapy; SSRI, Selective Serotonin Reuptake Inhibitor; ERP, Exposure Response Prevention; ACT, Acceptance Commitment Therapy; PET, Prolonged Exposure Therapy

Additional Information

  • When initiating SSRIs, start at half the dose for depression and increase dose more slowly
  • When initiating SSRIs in Generalized Anxiety Disorder and Panic Disorder, prescribe a benzodiazepine to mitigate initial anxiety/nausea common with initiation of SSRIs and to provide immediate relief as SSRIs typically take 2-6 weeks to work
  • SNRIs are also used (and effective) for Anxiety Disorders
  • There is little evidence supporting the use of Benzodiazepines in Social Anxiety Disorder, Obsessive Compulsive Disorder, and Post-Traumatic disorder
  • Benzodiazepines can be used as monotherapy for Panic Disorder and Generalized Anxiety Disorder (but SSRIs/SNRIs should be tried first)
  • Higher doses of SSRIs are usually required to relieve symptoms of Obsessive Compulsive Disorder

Antidepressant Tables

The first line medication treatment for anxiety are selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors which are also used to treat unipolar depression. 

Selective Serotonin Reuptake Inhibitors (SSRIs)Initial Dose (Range), mgComments
Fluoxetine (Prozac)20 (20-60)Activating. Long half-life. 2D6 Inhibitor.
Paroxetine (Paxil)20 (20-60)Anticholinergic. Sedating. 2D6 Inhibitor. Sexual side effects. D/C syndrome. Pregnancy risk.
Sertraline (Zoloft)50 (50-200)Activating. Dopaminergic. 2D6 Inhibitor at higher doses. GI side effects common early in tx.
Citalopram (Celexa)20 (20-60)Few interactions. QT prolongation (>40mg/day).
Escitalopram (Lexapro)10 (10-20)Few interactions. QT prolongation.
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Duloxetine (Cymbalta)30 (30-60)Short half life with risk of d/c symptoms. FDA approved for Diabetic neuropathy and Fibromyalgia. Morning dosing. Rarely sedating. May increase BP.
Venlafaxine XR (Effexor XR)37.5 (75-300)Nausea common. May increase BP. Once daily dosing with XR minimizes side effects (i.e., nausea). Reduce dose in renal insufficiency. May help with chronic pain.
Desvenlafaxine (Pristiq)50 (50-100)Active metabolite of venlafaxine. More noradrenergic activity than venlafaxine. Better choice for those with renal and hepatic insufficiency. May help with chronic pain. Short half-life with risk of d/c symptoms.
Atypical Antidepressants
Bupropion (Wellbutrin)100 (100-400)Noradrenergic and Dopaminergic. Minimal sexual side effects. May increase BP. Avoid in those with eating disorders or seizure hx. 2D6 inhibitor.
SR (BID dosing)150 (150-450)
XL (QAM dosing)
Trazodone (Desyrel)25 (25-400)Sedating. Commonly used for insomnia. May increase time in slow wave sleep. No anticholinergic properties. Histamine/α1 at low doses. Minimal sexual side effects. Warn about priapism. May be better for anxiety than depression.
Mirtazapine (Remeron)7.5 (7.5-45)Noradrenergic and serotonergic properties. Has actions at 5HT3 and therefore helps with nausea. Minimal sexual side effects. Sedation and weight gain common. Sedation usually limited to 7.5mg-15mg.

References

  1. Puzantian, T., & Carlat, D. J. (2016). Medication fact book: for psychiatric practice. Newburyport, MA: Carlat Publishing, LLC.
  2. J. Ferrando, J. L. Levenson, & J. A. Owen (Eds.), Clinical manual of psychopharmacology in the medically ill(pp. 3-38). Arlington, VA, US: American Psychiatric Publishing, Inc.
  3. Schatzberg, A. F., & DeBattista, C. (2015). Manual of clinical psychopharmacology. Washington, DC: American Psychiatric Publishing.
  4. Schatzberg, A. F., & Nemeroff, C. B. (2017). The American Psychiatric Association Publishing textbook of psychopharmacology. Arlington, VA: American Psychiatric Association Publishing.
  5. Stahl, S. M. (2014). Stahl’s essential psychopharmacology: Prescriber’s guide (5th ed.). New York, NY, US: Cambridge University Press.
  6. Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY, US: Cambridge University Press.
  7. Whalen, K., Finkel, R., & Panavelil, T. A. (2015). Lippincotts illustrated reviews: pharmacology. Philadelphia, PA: Wolters Kluwer.
  8. Stern, T. A., Freudenreich, O., Fricchione, G., Rosenbaum, J. F., & Smith, F. A. (2018). Massachusetts General Hospital handbook of general hospital psychiatry. Edinburgh: Elsevier.
  9. McCarron, Robert M., et al. Lippincotts Primary Care Psychiatry: for Primary Care Clinicians and Trainees, Medical Specialists, Neurologists, Emergency Medical Professionals, Mental Health Providers, and Trainees. Wolters Kluwer Health/Lippincott Williams & Wilkins, 2009.
  10. Levenson, J. L. (2019). The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. Washington, D.C.: American Psychiatric Association Publishing.
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