1000-2000 5 ьшò

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Collaborative care approach, including primary care visits and case manager follow-ups

Consultation with the infant’s doctor, particularly if the mother is breastfeeding while taking psychotropic medications

DIET

Good nutrition and hydration, especially when breastfeeding

Mixed evidence to support the addition of multivitamin with minerals and omega-3 fatty acids

PATIENT EDUCATION

This Isn’t What I Expected: Overcoming Postpartum Depression, by Karen R. Kleiman and Valerie Davis Raskin

Down Came the Rain: My Journey Through Postpartum Depression, by Brooke Shields, 2005

Behind the Smile: My Journey Out of Postpartum Depression, by Marie Osmond, Marcia Wilkie, and Judith Moore, 2001

Web resources

–Postpartum Support International: http://www.postpartum.net/

–La Leche League: http://www.llli.org/

–http://www.womensmentalhealth.org/

–http://www.motherisk.org/

–http://www.step-ppd.com/

PROGNOSIS

Treatment of maternal depression to remission has been shown to have a positive impact on children’s mental health.

Some patients, particularly those with undertreated or undiagnosed depression, may develop chronic depression requiring long-term treatment.

Untreated maternal depression is linked to impaired mother–infant bonding and cognitive and language development delay in infants and children (6).

Postpartum psychosis is associated with tragic outcomes such as maternal suicide and infanticide.

COMPLICATIONS

mebooksfree.com

Suicide

Self-injurious behavior

Psychosis

Neglect of baby

Harm to the baby

Preterm and low-birth-weight baby

REFERENCES

1.Stuart-Parrigon K, Stuart S. Perinatal depression: an update and overview.

Curr Psychiatry Rep. 2014;16(9):468.

2.Wisner KL, Sit DK, McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry. 2013;70(5):490–498.

3.Bobo WV, Yawn PB. Concise review for physicians and other clinicians: postpartum depression. Mayo Clin Proc. 2014;89(6):835–844.

4.Gavin NI, Gaynes BN, Lohr KN, et al. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106(5 Pt 1):1071– 1083.

5.Pearlstein T, Howard M, Salisbury A, et al. Postpartum depression. Am J Obstet Gynecol. 2009;200(4):357–364.

6.Fitelson E, Kim S, Baker AS, et al. Treatment of postpartum depression: clinical, psychological and pharmacological options. Int J Womens Health. 2010;3:1–14.

ADDITIONALREADING

Edinburgh Postnatal Depression Scale: https://pesnc.org/wpcontent/uploads/EPDS.pdf

Gjerdingen D, Katon W, Rich DE. Stepped care treatment of postpartum depression: a primary care-based management model. Womens Health Issues. 2008;18(1):44–52.

Harrington AR, Greene-Harrington CC. Healthy Start screens for depression among urban pregnant, postpartum and interconceptional women. J Natl Med Assoc. 2007;99(3):226–231.

Hirst KP, Moutier CY. Postpartum major depression. Am Fam Physician. 2010;82(8):926–933.

Howard LM, Boath E, Henshaw C. Antidepressant prevention of postnatal depression. PLoS Med. 2006;3(10):e389.

mebooksfree.com

Kendall-Tackett K. Anew paradigm for depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. Int Breastfeed J. 2007;2:6.

Musters C, McDonald E, Jones I. Management of postnatal depression. BMJ. 2008;337:a736.

Ng RC, Hirata CK, Yeung W, et al. Pharmacologic treatment for postpartum depression: a systematic review. Pharmacotherapy. 2010;30(9):928–941.

Sit DK, Wisner KL. Identification of postpartum depression. Clin Obstet Gynecol. 2009;52(3):456–468.

Tammentie T, Tarkka MT, Astedt-Kurki P, et al. Family dynamics and postnatal depression. J Psychiatr Ment Health Nurs. 2004;11(2):141–149.

CODES

ICD10

F53 Puerperal psychosis

O90.6 Postpartum mood disturbance

CLINICALPEARLS

PPD is a common, debilitating medical condition that impairs a mother’s ability to function and interact with her infant and family.

Universal screening for depression is recommended during the 1st and 3rd trimester and at regular intervals during the postpartum period.

Early diagnosis and treatment are vital, as untreated PPD can lead to developmental difficulties for the infant and prolonged disability and suffering for the mother.

Breastfeeding is recommended for maternal and child health. Several medication options for treating depression in mothers are safe for breastfeeding infants.

Treatment with antidepressants should be individualized for breastfeeding mothers (4)[B].

mebooksfree.com

DEPRESSION, TREATMENT RESISTANT

Michelle Magid, MD, MBA Roger Lowell McRoberts III, MD

BASICS

DESCRIPTION

Major depressive disorder (MDD) that has failed to respond to ≥2 adequate trials of antidepressant therapy in ≥2 different classes

Antidepressant therapy must be given for 6 weeks at standard doses before being considered a failure.

EPIDEMIOLOGY

Depression affects >16 million people in the United States and >350 million people worldwide.

16% lifetime risk of MDD

Approximately 1/3 of patients with MDD will develop treatment-resistant depression.

ETIOLOGYAND PATHOPHYSIOLOGY

Unclear. Low levels of neurotransmitters (serotonin, norepinephrine, dopamine) have been indicated.

Serotonin has been linked to irritability, hostility, and suicidal ideation.

Norepinephrine has been linked to low energy.

Dopamine may play a role in low motivation and depression with psychotic features.

Environmental stressors such as abuse and neglect may affect neurotransmission.

Inflammation and oxidative stress in the brain can contribute to treatmentresistant depression.

Genetics

Agenetic abnormality in the serotonin transporter gene (5-HTTLPR) may increase risk for treatment-resistant depression.

RISK FACTORS

mebooksfree.com

Severity of disease

Mislabeling bipolar patients as depressed

Comorbid medical disease (including chronic pain)

Comorbid personality disorder

Comorbid anxiety disorder

Comorbid substance use disorder

Familial predisposition to poor response to antidepressants

GENERALPREVENTION

Medication adherence in combination with psychotherapy

Maintenance electroconvulsive therapy (ECT) may prevent relapse.

COMMONLYASSOCIATED CONDITIONS

Suicide

Bipolar disorder

Substance use disorders

Anxiety disorders

Dysthymia

Eating disorders

Somatic symptom disorders

DIAGNOSIS

HISTORY

Symptoms are the same as in MDD. However, patients do not respond to standard form of treatment. Severity and duration are extreme.

Important to screen for suicidality in treatment-resistant depression Screening with SIGECAPS

–Sleep: too much or too little

–Interest: failure to enjoy activities

–Guilt: excessive and uncontrollable

–Energy: poor energy

–Concentration: inability to focus on tasks

–Appetite: too much or too little

–Psychomotor changes: restlessness/agitation or slowing/lethargy

–Suicidality: desire to end life

mebooksfree.com

PHYSICALEXAM

Mental status exam may reveal poor hygiene, poor eye contact, blunted affect, tearfulness, weight loss or gain, psychomotor retardation, or agitation.

DIFFERENTIALDIAGNOSIS

Bipolar disorder

Dysthymia

Dementia

Early-stage Parkinson disease

Personality disorder

Medical illness such as malignancy, thyroid disease, HIV

Substance use disorders

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Used to rule out medical factors that could be causing/contributing to treatment resistance

–CBC

–Complete metabolic profile, including liver tests, calcium, and glucose

–Urine drug screen

–Thyroid-stimulating hormone (TSH)

–Vitamin D level (25-OH vitamin D)

–Testosterone, if applicable

CT or MRI of the brain if neurologic disease, tumor, or dementia is suspected.

Follow-Up Tests & Special Considerations

Delirium and dementia may often look like depression.

Diagnostic Procedures/Other

Depression is a clinical diagnosis. Validated depression rating scales to assist

–Beck Depression Inventory

–Hamilton Depression Rating Scale

–Patient Health Questionnaire 9 (PHQ-9)

mebooksfree.com

TREATMENT

MEDICATION

First Line

Please see “Depression” topic. When those fail, augmentation and combination strategies are as follows:

–Antidepressants in combination

Citalopram (start 20 mg/day; max dose 40 mg/day) + bupropion (start 100 mg BID; max dose 450 mg total) (1)[B]

Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) may be used in combination. Proceed with caution due to risk of serotonin syndrome; citalopram (start 20 mg/day; max dose 40 mg/day) + nortriptyline (start 50 mg at bedtime; max dose 150 mg at bedtime)

–Antidepressants + antipsychotics

Citalopram (start 20 mg/day; max dose 40 mg/day) + aripiprazole (2 to 5 mg/day, different mechanism of action at higher doses) OR + risperidone (start 0.5 to 1.0 mg at bedtime; max dose 6 mg/day) or + quetiapine (start 25 mg at bedtime; titrate to 100 to 300 mg at bedtime; max dose 600 mg/day) (2)[A]

–Antidepressant + lithium

TCA: nortriptyline (start 50 mg at bedtime; max dose 150 mg at bedtime)

+lithium (start 300 mg at bedtime; max dose 900 mg BID) (3)[A]

SSRI: citalopram (start 20 mg/day; max dose 40 mg QD) + lithium (start 300 mg at bedtime; max dose 900 mg BID)

–Antidepressant + thyroid supplementation

Citalopram (start 20 mg/day; max dose 40 mg/day) + triiodothyronine (T3) (12.5 to 50 µg/day)

In all above combinations, citalopram (Celexa) can be replaced with other SSRIs such as fluoxetine (Prozac) 20 to 80 mg/day, sertraline (Zoloft) 50 to 200 mg/day, and escitalopram (Lexapro) 10 to 20 mg/day or with serotoninnorepinephrine reuptake inhibitors (SNRIs) duloxetine (Cymbalta) 30 to 120 mg/day, venlafaxine XR (Effexor XR) 75 to 225 mg/day, or desvenlafaxine (Pristiq) 50 to 100 mg/day, or with a noradrenergic and specific serotonergic antidepressant (NaSSA) mirtazapine (Remeron) 15 to 45 mg at bedtime.

Maximum doses for medication in treatment-resistant cases may be higher than in treatment-responsive cases.

mebooksfree.com

Second Line

Antidepressant in combination with therapy—in particular cognitivebehavioral therapy (CBT) (4)[B]

Monoamine oxidase inhibitor (MAOI)

Tranylcypromine (Parnate): start 10 mg BID, increase 10 mg/day every 1 to 3 weeks; max dose 60 mg/day

Selegiline transdermal (Emsam patch): apply 6-mg patch daily, increase 3 mg/day; max dose 12 mg/day

Side-effect profile (e.g., hypertensive crisis), drug–drug interactions, and dietary restrictions make MAOIs less appealing. Patch version does not require dietary restrictions at lower doses.

High risk of serotonin syndrome, if combined with another antidepressant; 2- week washout period is advised.

ISSUES FOR REFERRAL

Treatment-resistant depression should be managed in consultation with a psychiatrist.

ADDITIONALTHERAPIES

First line

–ECT: safe and effective treatment for treatment-resistant and lifethreatening depression, with a 60–90% success rate (5)[A]:

Known to rapidly relieve suicidality, psychotic depression, and catatonia

Controversy due to cognitive side effects during the treatment

Three types of lead placements

■Bitemporal: rapid and effective; usually need 6 to 10 treatments at 1.5 times seizure threshold

■Right unilateral: may be slightly less rapid but fewer cognitive side effects; usually need 8 to 12 treatments at 6 times seizure threshold

■Bifrontal: newer technique that may offer similar speed to bitemporal,

with slightly improved side-effect profile Second line

–Deep brain stimulation (DBS): surgical implantation of intracranial electrodes, connected to an impulse generator implanted in the chest wall: Reserved for those who have failed medications, psychotherapy, and ECT Preliminary data are promising, showing 40–70% response rate and 35% remission rate, but further trials are warranted.

–Transcranial magnetic stimulation (TMS): noninvasive brain stimulation

mebooksfree.com

technique that is generally safe. Afew case reports on efficacy in treatmentresistant depression but thus far is only FDAapproved for less severe forms of the illness (3)[C].

–Vagus nerve stimulation (VNS): Surgical implantation of electrodes onto left vagus nerve. Its use in treatment-resistant depression has become limited in recent years.

–Ketamine—not FDAapproved, but evidence of rapid improvement in mood and suicidal thinking, although the literature is limited. In addition, the effects of ketamine appear temporary, disappearing after days to weeks (3,6)[C].

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Inpatient care is indicated for severely depressed, psychotic, catatonic, or suicidal patients.

Discharge criteria: symptoms improving, no longer suicidal, psychosocial stressors addressed

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Frequent visits (i.e., every month)

During follow-up, evaluate side effects, dosage, and effectiveness of medication as well as need for referral to ECT.

Patients who have responded to ECT may need maintenance treatments (q3– 12wk) to prevent relapse.

Combination of lithium/nortriptyline after ECT appears to be as effective as maintenance ECT in reducing relapse.

DIET

Patients on MAOIs need dietary restriction.

PATIENT EDUCATION

Educate patients that depression is a medical illness, not a character defect.

Review signs and symptoms of worsening depression and when patient needs to come in for further evaluation.

mebooksfree.com

Discuss safety plan to address suicidal thoughts.

PROGNOSIS

With medication adherence, close follow-up, improved social support, and psychotherapy, prognosis improves.

COMPLICATIONS

Suicide

Disability

Poor quality of life

REFERENCES

1.Trivedi MH, Fava M, Wisniewski SR, et al; for STAR*D Study Team. Medication augmentation after the failure of SSRIs for depression. N Engl J Med. 2006;354(12):1243–1252.

2.Maglione M, Maher AR, Hu JH, et al. Off-Label Use of Atypical Antipsychotics: An Update. Rockville, MD: Agency for Healthcare Research and Quality; 2011.

3.Holtzheimer PE. Advances in the management of treatment-resistant depression. Focus (Am Psychiatr Publ). 2010;8(4):488–500.

4.Wiles NJ, Thomas L, Turner N, et al. Long-term effectiveness and costeffectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: followup of the CoBalT randomised controlled trial. Lancet Psychiatry. 2016;3(2):137–144.

5.Weiner RD. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging: A Task Force Report of the American Psychiatric Association. 2nd ed. Washington, DC: American Psychiatric Association; 2001:5–25.

6.Caddy C, Giaroli G, White TP, et al. Ketamine as the prototype glutamatergic antidepressant: pharmacodynamic actions, and a systematic review and metaanalysis of efficacy. Ther Adv Psychopharmacol. 2014;4(2):75–99.

CODES

ICD10

F32.9 Major depressive disorder, single episode, unspecified

mebooksfree.com