1000-2000 5 ьшò

extended release and titrate weekly. Treatment range 150 to 225 mg/day; may be associated with elevated BPat higher doses (5)[C]

Duloxetine: Start at 20 to 30 mg/day. Treatment range 60 to 120 mg/day. Also, duloxetine may be associated with elevated BP(5)[A].

Mirtazapine: Start at 7.5 to 15 mg nightly. Treatment range 30 to 45 mg/day; can produce problems with dry mouth, weight gain, sedation, and cognitive dysfunction (5)[A]

Desvenlafaxine: 50 mg/day in AM; higher doses do not confer additional benefit; 50 mg every other day if CrCl <30 mL/min (5)[A]

ISSUES FOR REFERRAL

Depression with suicidal ideation, psychotic depression, bipolar disorder, comorbid substance abuse issues, polypharmacy, severe or refractory illness

ADDITIONALTHERAPIES

For patients who have not responded to initial SSRI trial:

– Switch to a different SSRI medication, switch to an atypical antidepressant, or augment initial antidepressant with bupropion.

2nd-generation antipsychotic agents (5)[C]:

–Aripiprazole: 2 to 5 mg/day. Treatment range 5 to 15 mg/day; can produce sedation, weight gain, increased cholesterol levels

–Should only be used for augmentation in conjunction with other

antidepressant medications Tricyclic antidepressants (TCAs):

–Nortriptyline: 25 to 50 mg nightly. Treatment range 75 to 150 mg nightly; can produce anticholinergic effects, weight gain, increase risk of falls (5)[C]

–TCAs have been shown to be effective in treating depression in the elderly. However, they are difficult for elderly patients to tolerate due to side effect

profile and are potentially lethal in overdose, limiting their use as initial treatment agents (6)[A].

MAOIs also appear more effective than placebo in the treatment of depression in the elderly. They are not used frequently in clinical practice due to potential side effects and necessary dietary restrictions (6)[A].

Although not FDA-approved, buspirone, lithium, or triiodothyronine are sometimes used off-label to augment a primary antidepressant. Evidence for benefit of antidepressants in the treatment of depression in patients with dementia is equivocal. Consideration should be made for a

limited trial with close monitoring for symptom improvement or side effects

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and used only in patients with severe symptoms.

Electroconvulsive therapy (ECT): has been shown to produce remission of depressive symptoms in the elderly. It should be considered as an initial option for patients with severe or psychotic depression.

COMPLEMENTARY& ALTERNATIVE MEDICINE

Acupuncture: equally beneficial as counseling

St. John’s wort may have minimal benefit and has numerous drug interactions.

Tryptophan and hydroxytryptophan: 150 to 300 mg/day; possible efficacy, additional investigation required

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Inpatient care is indicated in cases of imminent safety risk (e.g., acutely suicidal patients) or for those patients unable to care adequately for themselves due to depression.

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Due to the delay of benefit following initiation of antidepressant therapy, it is necessary to ensure open communication with the patient to prevent premature discontinuation of therapy. An adequate explanation of potential side effects with instructions to call the office before discontinuing therapy is imperative.

Patient Monitoring

Apatient with severe depression who exhibits suicidality will require admission to an appropriate facility.

Monitor for worsening anxiety symptoms or increase in suicidality especially in the week following initiation of antidepressants.

DIET

No dietary restrictions are necessary, except for patients taking MAOIs, which necessitates dietary restriction of foods high in tyramine (i.e., certain cheeses and wines).

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PATIENTEDUCATION

Depression is a treatable illness.

Medications may need to be taken for at least 2 to 4 weeks before any beneficial effect is noted and may take 6 to 8 weeks to reach maximum efficacy.

Depression is often a recurring illness.

National Suicide Prevention Lifeline at 1-800-273-TALK (8255) is a free, 24hour hotline available to anyone in suicidal crisis or emotional distress. Calls will be routed to the nearest crisis center.

PROGNOSIS

Treatment outcomes in the elderly may be worse than in the general population, possibly mediated by physical comorbidities and other factors.

Depending on the population studied and specific clinical measures used, estimates vary for initial clinical response and remission (between 30% and 70%).

COMPLICATIONS

Impairment in social, occupational, or interpersonal functioning

Difficulty performing activities of daily living and self-care

Increase in medical services utilization and increased costs of care

Suicide

REFERENCES

1.Blake H, Mo P, Malik S, et al. How effective are physical activity interventions for alleviating depressive symptoms in older people? A systematic review. Clin Rehabil. 2009;23(10):873–887.

2.Wilson KC, Mottram PG, Vassilas CA. Psychotherapeutic treatments for older depressed people. Cochrane Database Syst Rev. 2008;(1):CD004853.

3.Wilson K, Mottram P, Sivanranthan A, et al. Antidepressant versus placebo for depressed elderly. Cochrane Database Syst Rev. 2001;(2):CD000561.

4.Ruhé HG, Huyser J, Swinkels JA, et al. Switching antidepressants after a first selective serotonin reuptake inhibitor in major depressive disorder: a systematic review. J Clin Psychiatry. 2006;67(12):1836–1855.

5.Nelson JC, Delucchi K, Schneider LS. Efficacy of second generation antidepressants in late-life depression: a meta-analysis of the evidence. Am J Geriatr Psychiatry. 2008;16(7):558–567.

6.Taylor WD. Clinical practice. Depression in the elderly. N Engl J Med.

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2014;371(13):1228–1236.

SEE ALSO

Algorithms: Depressed Mood Associated with Medical Illness; Depressive

Episode, Major

CODES

ICD10

F32.9 Major depressive disorder, single episode, unspecified

F03 Unspecified dementia

F43.21 Adjustment disorder with depressed mood

CLINICALPEARLS

Depression is not a normal part of aging.

Depression in the elderly may be difficult to diagnose precisely due to medical and cognitive comorbidities.

Depression may present primarily with cognitive dysfunction, and this may improve with treatment of the depression.

Amultidisciplinary approach to the treatment of depression is often the most efficacious.

SSRIs are considered first-line therapy for safety and tolerability. Afull remission may take upward of 12 weeks of treatment. Long-term treatment may be needed to prevent recurrence.

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DEPRESSION, POSTPARTUM

Misty Stafford, MD Nancy Byatt, DO, MBA, FAPM

BASICS

DESCRIPTION

Major depressive disorder (MDD) that recurs or has its onset in the postpartum period

May also occur in mothers adopting a baby or in fathers

Postpartum depression (PPD) is similar to nonpregnancy depression (sleep disorders, anhedonia, psychomotor changes, etc.); it most often has its onset within the first 12 weeks postpartum yet can occur within 1 year after delivery.

Different than postpartum “blues” (sadness and emotional lability), which is experienced by 30–70% of women and has an onset and resolution within first 10 days postpartum

EPIDEMIOLOGY

Incidence

14.5% of women have a new episode of major or minor depression during postpartum period (1).

Prevalence

>50% of women with PPD enter pregnancy depressed or have an onset during pregnancy (2).

As many as 19.2% women suffer from depression within 3 months postpartum period (3).

ETIOLOGYAND PATHOPHYSIOLOGY

May be related to sensitivity in hormonal fluctuations, including estrogen; progesterone; and other gonadal hormones as well as neuroactive steroids; cytokines; hypothalamic–pituitary–adrenal (HPA) axis hormones; altered fatty acid, oxytocin, and arginine vasopressin levels; and genetic and epigenetic factors

Multifactorial including biologic–genetic predisposition in terms of neurobiologic deficit, destabilizing effects of hormone withdrawal at birth,

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inflammation, and psychosocial stressors

RISK FACTORS

Previous episodes of PPD

History of MDD

MDD during pregnancy

Anxiety during pregnancy

History of premenstrual dysphoria

Family history of depression

Unwanted pregnancy

Socioeconomic stress

Low self-esteem

Young maternal age

Alcohol abuse

Marital conflict

Multiple births

African Americans and Hispanics may have higher rates of PPD.

Postpartum pain, sleep disturbance, and fatigue

Recent immigrant status

Increased stressful life events

History of childhood sexual abuse

Decision to decrease antidepressants during pregnancy

Intimate partner violence (4)

Prepregnancy diabetes

GENERALPREVENTION

Universal screening during pregnancy to allow for detection and treatment

Screen using Edinburgh Postnatal Depression Scale during pregnancy and postpartum year.

Postnatal visits, psychotherapy, and/or psychoeducation for high-risk women

For women with depression during pregnancy, psychotherapy or treatment with antidepressants during pregnancy may prevent PPD.

Depression care manager who provides education, routine telephone contact, and follow-up to engage women in treatment

COMMONLYASSOCIATED CONDITIONS

Bipolar mood disorder

Depressive disorder not otherwise specified

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Dysthymic disorder

Cyclothymic disorder

MDD

DIAGNOSIS

HISTORY

Increased/decreased sleep

Decreased interest in formerly compelling or pleasurable activities

Guilt, low self-esteem

Decreased energy

Decreased concentration

Increased/decreased appetite

Psychomotor agitation or retardation

Suicidal ideation

DIFFERENTIALDIAGNOSIS

Baby blues: not a psychiatric disorder; mood lability resolves within days.

Postpartum psychosis: a psychiatric emergency

Postpartum anxiety/panic disorder

Postpartum obsessive-compulsive disorder

Hypothyroidism

Postpartum thyroiditis: can occur in up to 5.7% of patients in the United States and can present as depression (5)

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Thyroid-stimulating hormone (TSH), B12, folate, and Vitamin D

Diagnostic Procedures/Other

Edinburgh Postnatal Depression Scale is a validated screening tool.

The Patient Health Questionnaire-9 (PHQ-9) is a validated commonly used screening tool.

Edinburgh Postnatal Depression Scale (partner version): to be completed by mother’s partner to obtain his/her view of mother’s depression

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TREATMENT

GENERALMEASURES

Outpatient individual psychotherapy in combination with pharmacotherapy

Interpersonal psychotherapy and cognitive behavioral therapy

Strongly consider pharmacotherapy when symptoms are moderate or severe.

Assess suicidal ideation.

Assess homicidal ideation and thoughts of harming baby.

Thoughts of harming the baby require immediate hospitalization.

Visiting nurse services can provide direct observations of the mother regarding safety concerns and mother–child bonding.

MEDICATION

First Line

For nonbreastfeeding women, selection of antidepressants is similar to nonpostpartum patients.

Selective serotonin reuptake inhibitors (SSRIs) are generally effective and safe:

–Fluoxetine (Prozac): 20 to 80 mg/day PO (most activating of all SSRIs)

–Sertraline (Zoloft): 50 to 200 mg/day PO (mildly sedating)

–Paroxetine (Paxil): 20 to 60 mg/day PO (sedating)

–Citalopram (Celexa): 20 to 40 mg/day PO (FDArecommendation)

–Escitalopram (Lexapro): 10 to 20 mg/day PO

Tricyclic antidepressants (TCAs) are effective and less expensive yet also are lethal in overdose and have unfavorable side effects:

– Avoid TCAs in mothers with a history of suicidal ideation.

Bupropion (Wellbutrin): 150 to 450 mg/day PO in patients with depression plus psychomotor retardation and hypersomnia and with weight gain. Bupropion is less likely to cause weight gain or sexual dysfunction and is highly activating.

Mirtazapine (Remeron): 15 to 45 mg/day PO at bedtime; may assist with sleep restoration and weight gain; no sexual dysfunction Serotonin-norepinephrine reuptake inhibitors (SNRIs)

–Venlafaxine (Effexor XR): a dual-action antidepressant that blocks the reuptake of serotonin in doses of up to 150 mg/day and then blocks the reuptake of norepinephrine in doses of 150 to 450 mg/day PO

–Duloxetine (Cymbalta): more balanced serotonin/norepinephrine reuptake

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throughout dosing; 40 to 60 mg/day PO (doses >60 mg have not been demonstrated to be more effective)

– Desvenlafaxine (Pristiq): 50 mg/day PO

Bipolar disorder requires treatment with mood stabilizer. Among breastfeeding mothers

–Breastfeeding should generally not preclude treatment with antidepressants.

–SSRIs and some other antidepressants are considered a reasonable option during breastfeeding.

–All antidepressants are excreted in breast milk but are generally compatible with lactation.

–Paroxetine and sertraline have lower translactal passage.

–SSRIs and nortriptyline have a better safety profile.

–Translactal passage is greater with fluoxetine and citalopram (4)[B].

–Start with low doses and increase slowly. Monitor infant for adverse side effects.

–Continuing an efficacious medication is preferred over switching antidepressants to avoid exposing the mother and infant to the risks of untreated PPD (4)[B].

–Breastfeeding women need additional education and support regarding the risks and benefits of use of antidepressants during breastfeeding.

–Consider negative effects of untreated PPD on infant and child development.

–Discussions of the treatment options with the patient and her partner when possible. Take into account the patient’s personal psychiatric history and previous response to treatment, the risks of no treatment or undertreatment, available data about the safety of medications during breastfeeding, and her individual expectations and treatment preferences.

–For further information: http://toxnet.nlm.nih.gov/

Second Line

Consider switching to a different antidepressant or augmentation if patient has a lack of response. Electroconvulsive therapy (ECT) is an option for depressed postpartum women who do not respond to antidepressant medications, have severe or psychotic symptoms, cannot tolerate antidepressant medications, are actively engaged in suicidal self-destructive behaviors, or have a previous history of response to ECT (5)[B].

ISSUES FOR REFERRAL

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Obtain psychiatric consultation for patients with psychotic symptoms.

Strongly consider immediate hospitalization if delusions or hallucinations are present.

Hospitalization is indicated if mother’s ability to care for self and/or infant is significantly compromised.

ADDITIONALTHERAPIES

Psychoeducation, including providing reading material for the patient and family

Psychotherapy: Interpersonal psychotherapy, cognitive behavioral therapy, and psychodynamic psychotherapy have shown to be effective.

COMPLEMENTARY& ALTERNATIVE MEDICINE

Breastfeeding has been associated with reduced stress and improved maternal mood.

Infant massage, infant sleep intervention, exercise, and bright light therapy may be beneficial (5)[B].

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

ALERT

Obtain psychiatric consultation for patients with psychotic symptoms. If delusions or hallucinations are present, strongly consider immediate hospitalization. The psychotic mother should not be left alone with the baby.

Admission criteria/initial stabilization: presence of suicidal or homicidal ideation and/or psychotic symptoms and/or thoughts of harming baby and/or inability to care for self or infant, severe weight loss

Discharge criteria

–Absence of suicidal or homicidal ideation and/or psychotic symptoms and/or thoughts of harming the baby

–Mother must be able to care for self and infant.

ONGOING CARE

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