Welcome to the third and final post in this series on depression! In the first post, we discussed routine screening and diagnosis of depression, and last time we talked about the 5 aspects of “treatment” that can be helpful for patients with depression. Today we’ll delve into one of those 5 areas of treatment – medication management.
As I’ve mentioned before, I had a preceptor tell me during one of my NP clinical rotations to pick my “favorite” medications for each condition and use them whenever appropriate; this helps you to get familiar with a smaller number of medications, and reduces the overwhelming-ness of starting to be a prescriber! I have stuck with that strategy throughout my practice, including in my treatment of patients with depression. My go-to medication for depresion is Effexor (generic name – venlafaxine). That being said, if a patient comes to me on another medication (ie. Zoloft [sertraline], Paxil [paroxetine] or Brintellix [vortioxetine]) and is well-controlled, I’m not going to switch them to another medication just because it’s the one I prefer. However, if they’re not well-controlled on their current medication (which you’ll know from their PHQ-2/PHQ-9 score) OR they’re not on anything at all, I will often suggest a switch.
Also, I always prescribe generics – for everything; so even though I’m saying “Effexor”, what I really mean is venlafaxine XR. Venlafaxine is an SNRI – a serotonin-norepinephrine reuptake inhibitor. So, as opposed to an SSRI (selective serotonin reuptake inhibitor) which works on serotonin concentrations only, SNRIs like venlafaxine increases the concentrations of both serotonin and norepinephrine. Sometimes, however, there are good reasons to use a different antidepressant, depending on the patient’s condition. For example, duloxetine (Cymbalta) is a great choice for patients who also have chronic pain, fibromyalgia, or neuropathic pain (though not a good choice in patients who have liver problems or drink heavily). Buproprion (Wellbutrin) is a good choice for patients who also want to quit smoking (though not a good choice for patients with seizures, as it lowers the seizure threshold). And mirtazapine (Remeron) or trazodone (Oleptro) are great choices for patients who also struggle with insomnia.
When starting an antidepressant, it’s important to let patients to know what to expect. Here are a few highlights of this group of medications, as a whole:
- It typically takes about 4 – 6 weeks for the full effect of a given dose to take effect, though a patient may see some improvements after as few as 2 weeks.
- Nausea and GI side effects are common when starting these medications, though they typically improve when the medication is taken with food and typically improve after 1 – 2 weeks
- SSRIs may cause sexual side effects, including delayed ejaculation in men and inability to have an orgasm in women
- May cause drowsiness OR insomnia; adjust the timing of administration if this results
- It’s very important to take at about the same time each day, and not to miss doses, as withdrawal side effects may occur. ( I learned this the hard way at my first NP job when I refused to refill an SNRI for a patient who hadn’t followed up in the timeframe I’d specified; she had awful withdrawal side effects and didn’t let me forget it. Now my practice is to always provide a 30-day supply and let the patient know that he/she will need to follow up within that window for any further refills.)
- Occasionally, starting antidepressants makes depression worse, especially in patients younger than 25. If suicidal or homicidal ideation develop, that is an emergency and the patient should proceed directly to the emergency department
If, when you re-evaluate a patient, there is the need to change a medication, that can be done. Another set of bullet points! 🙂
- If you are switching from an SSRI (like fluoxetine) to an SNRI (like venlafaxine), you can make the switch immediately; for example, take your Prozac today and then start your Effexor tomorrow.
- If, however, you’re going the other direction OR stopping an antidepressant altogether, the patient needs to be tapered off the medication and not abruptly discontinued. If you’re going from an SNRI (like venlafaxine) to an SSRI (like escitalopram), titrate the patient down on the SNRI while titrating UP the SSRI. For example, if the patient is on venlafaxine 37.5mg once daily and the desired medication is escitalopram 10mg, I’d do venlafaxine 37.5 mg every other day for 2 weeks and do escitalopram 10mg on the alternate days, and then do venlafaxine 37.5 mg every third day for 2 weeks with escitalopram 10mg on the alternate days, and then start the escitalopram 10mg daily.
- If you’re stopping an antidepressant altogether and not restarting another one, I’d dose every-other-day for 2 weeks, then every third day for 2 weeks, and then stop. that should help the patient avoid any undesirable withdrawal effects.
- This can be complicated, so I typically include a calendar for the patient to follow so they don’t get confused. For example, here’s a sample one I’d give to a patient switching from venlafaxine to escitalopram:
So, how do you assess how well your therapeutic strategy is working? Well, first of all, don’t forget to continue addressing the other treatment modalities for depression I mentioned last time – counseling, exercise, social support, and a sense of purpose all remain important in the ongoing treatment of depression. For ongoing assessment of a patient’s depression, continue to use the PHQ-2/PHQ-9 tool at every office visit for patients who are receiving antidepressant therapy and record those findings in your note so you can compare from one visit to the next. If you’re titrating up the dose of an antidepressant without a noticeable impact on the patient’s subjective or objective experience of depression, it may be time to consider a change in medication or perhaps adding on an adjuvant medication. No patient should be on both an SSRI and an SNRI, but patients can be on an SSRI or an SNRI along with another agent. I would consider the patient’s other characteristics, and add a second agent if needed. I tend to use buproprion (Wellbutrin) in patients who also smoke and are interested in quitting (not typically my first-line choice, though), or mirtazapine (Remeron) or trazodone (Oleptro) if the patient also has insomnia.
And sometimes you have to know your limits. If you’ve tried multiple agents without much success, I’d refer to a psychiatric provider for further evaluation and management. That’s the beauty of primary care – we can manage (and manage well!) most conditions we see, but sometimes it’s time to call in the specialists. I know that mental health providers are hard to come by, at least around here; my goal is to keep those providers as freed-up for the more complex mental health patients (bipolar disorder, schizophrenia, refractory depression) by managing as much of it in primary care as I can.
In general, once a patient is stable on his/her antidepressant therapy, I see him/her every 6 months or so. Until they’re stable, though, I usually see them every 4 – 6 weeks for medication adjustments and re-evaluation of therapy. And I’ll reassess their ongoing need for antidepressants too; some people need them for life, but others just for “seasons”. As their PHQ-9 score comes down to near-zero, it may be worth a discussion about whether or not they’d like to try to taper off of it.
And that’s it for depression! Any other strategies you use for managing patients with depression? What is your go-to antidepressant? If you’re interested in medication profile posts on a specific antidepressant, let me know in the comments!