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Dr. Bob is Robert Hsiung, MD,
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Posted by Phillipa on March 25, 2009, at 18:54:19
Taken from a test for nurses, docs, and pharmacists with out giving the test this is the info for testing. Interesting. So if you wonder why your doc won't prescribe a med this could be why. Phillipa
Pharmacologic Treatments of Adults With Depression in Primary Care CME/CE
News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD
DisclosuresRelease Date: March 31, 2008; Valid for credit through March 31, 2009 Credits Available
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s) for physicians;
Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians;
Nurses - 0.25 nursing contact hours (0.25 contact hours are in the area of pharmacology)
To participate in this internet activity: (1) review the target audience, learning objectives, and author disclosures; (2) study the education content; (3) take the post-test and/or complete the evaluation; (4) view/print certificate View details.Learning Objectives
Upon completion of this activity, participants will be able to:Describe outcomes of medical treatment of depression and predictors of treatment success.
Identify appropriate treatment intervals of antidepressant therapy.
Authors and Disclosures
Laurie Barclay, MD
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.Charles Vega, MD
Disclosure: Charles Vega, MD, has disclosed an advisor/consultant relationship to Novartis, Inc.Brande Nicole Martin
Disclosure: Brande Nicole Martin has disclosed no relevant financial information.March 31, 2008 An overview of pharmacologic treatments for adults with depression in the primary care setting is published in the March 15 issue of the American Family Physician. The authors of this overview recommend close follow-up when therapy is initiated and dosages are adjusted, in part because of possible increase in suicide risk.
"Depression is common in primary care patients, with an incidence from 10 to 14 percent among patients who present to a physician's office for any reason," write Stephen M. Adams, MD, from the University of Tennessee College of Medicine in Chattanooga, and colleagues. "The use of antidepressants is increasing, having doubled in the United States between the years 1995 and 2002. The number of medication choices has likewise grown."
Despite extensive testing of antidepressants, the review authors note that several important questions remain unanswered because most trials of antidepressants have been of brief duration and have been sponsored by industry. Evidence from systematic reviews highlights concerns that available efficacy data may be limited by publication bias, and findings of small differences between antidepressants and active placebos (placebos that mimic antidepressant adverse effects) also support the need for methodologically well-designed trials of sufficient duration.
The reviewers point out that major depression is both highly prevalent and treatable, with pharmacotherapy likely to benefit many patients. In light of the narrow range of variation in antidepressant efficacy, a specific medication should be chosen after consideration of patient characteristics, safety profile, and likely adverse effects.
Although most patients have a good response to antidepressants, symptom relief is incomplete in some. For patients with partial or no response, changing medications or augmenting with a second medication may be helpful.
Clinicians should be aware that all antidepressant drugs may be associated with harmful adverse effects and that some are particularly prone to dangerous drug-drug interactions.
"The risk of suicide is always a concern in depression and this risk is not necessarily reduced by the use of antidepressants," the reviewers write. "Some persons may have an increase in suicidal thoughts with antidepressant treatment. Close follow-up is required when initiating therapy and adjusting dosages."
Specific clinical recommendations, and their accompanying level of evidence rating, are as follows:
Compared with placebo, antidepressants relieve symptoms of depression in adults. There are not important differences in effectiveness among antidepressants (level of evidence, A).
Before considering a particular treatment regimen to be ineffective, depression should be treated with adequate doses of antidepressant for a minimum of 4 to 8 weeks (level of evidence, C).
Patients taking antidepressants should be monitored for adverse effects, suicidality, and effectiveness (level of evidence, C).
If there is no improvement after 4 to 12 weeks of antidepressant treatment, a change in therapy should be considered (level of evidence, B).
After treatment failure with a particular antidepressant, appropriate therapeutic options may include a different medication of the same class, a medication from a different class, or augmentation with a second agent (level of evidence, B).
Tricyclic antidepressants (TCAs) block norepinephrine reuptake pumps as well as serotonin reuptake pumps to some extent. Their effects on acetylcholine, histamine, and adrenergic receptors are often associated with adverse effects such as weight gain, sedation, constipation, dry mouth, orthostatic hypotension, and reflex tachycardia.Compared with selective serotonin reuptake inhibitors (SSRIs), TCAs are more likely to cause significant cardiovascular events in patients with ischemic heart disease, and they are more lethal in overdose.
Since the introduction of fluoxetine (Prozac; Eli Lilly) in 1986, the SSRIs rapidly became the most widely used treatment for depression in the United States. These drugs inhibit presynaptic serotonin reuptake; venlafaxine (Effexor; Wyeth) and duloxetine (Cymbalta; Eli Lilly) inhibit serotonin and norepinephrine reuptake at higher doses. Adverse effects sometimes associated with the SSRIs include agitation, insomnia, gastrointestinal tract disturbances including nausea and diarrhea, and sexual dysfunction in both sexes.
Although amitriptyline may be slightly more effective than other antidepressants, it causes more adverse effects. A meta-analysis suggests that fluoxetine may be slightly less effective vs other antidepressants. More patients may have an early response to venlafaxine vs SSRIs, but this drug is more likely than the SSRIs to elevate diastolic blood pressure and cause dizziness, nausea, and vomiting.
Bupropion may have fewer sexual adverse effects than the SSRIs and may promote modest weight loss, but it is more likely to cause insomnia and headache. Of the SSRIs, paroxetine typically causes the most weight gain and fluoxetine the least.
"Compared with TCAs and MAOIs [monamine oxidase inhibitors], the primary advantages of the newer classes of antidepressants are their safety and tolerability," the reviewers conclude. "The use of an SSRI or SNRI [selective norepinephrine reuptake inhibitor] instead of a TCA doubles the likelihood that a patient will complete 90 days of treatment. . . . The choice of initial treatment with antidepressants should be based on safety, anticipated side effects, and cost."
The review authors have disclosed no relevant financial relationships.
Am Fam Physician. 2008;77:785-792, 795-796.
Clinical Context
The prevalence of depression in primary care practices is between 10% and 14%, and many of these patients eventually are considered for medical therapy for depression. Of patients treated for depression, approximately one half will respond to treatment, but only one third of patients treated with a single antidepressant achieve remission. Patients more likely to respond to treatment have a lower baseline severity of depression, a higher educational level and income, and a shorter duration of depression.There are now many choices for the pharmacologic management of depression. The current article by Adams and colleagues reviews the benefits and risks for these treatments.
Study Highlights
Overall, antidepressants are more effective than placebo in the treatment of depression in adults, but there is little difference between antidepressants in their efficacy. 1 review suggested that fluoxetine is slightly less effective vs other antidepressants.
The number of patients needed to treat to achieve 1 more responder to therapy is 4 for TCAs and 6 for SSRIs. 1 review found that lower dosages of TCAs are as effective as higher doses for depression. However, TCAs are associated with a much higher rate of adverse events vs SSRIs, including a higher risk for cardiovascular events among patients with ischemic heart disease and increased lethality in overdose.
SSRIs are the most popular treatment of depression in the United States, but they can promote agitation, insomnia, and sexual dysfunction in both men and women. SSRIs can also increase the risk for gastrointestinal tract hemorrhage. Paroxetine promotes the most weight gain among the SSRIs, and fluoxetine is the least likely to promote weight gain.
SSRIs, particularly fluvoxamine, fluoxetine, and paroxetine, can inhibit the metabolism of drugs through the cytochrome P450 system. In particular, SSRIs can increase levels of TCAs, phenytoin, and benzodiazepines.
Venlafaxine may promote an earlier treatment response vs SSRIs, but it can increase rates of elevated diastolic blood pressure, dizziness, and nausea and vomiting vs SSRIs.
Hypericum perforatum (St. John's wort) has performed well in only some studies of patients with mild to moderate depression, and its benefits may be limited among these patients. This treatment also has the potential for drug-drug interactions.
The choice for an initial antidepressant should be based on safety, anticipated adverse effects, and cost. SSRIs, SNRIs, or bupropion are reasonable choices, and TCAs may be used in select patients.
An adequate trial of antidepressant therapy is 4 to 8 weeks, and a change in treatment should be considered if there is no response after 4 to 12 weeks of treatment.
If remission is achieved with treatment, the antidepressant should be continued for at least 6 to 12 months.
If a change of treatment is considered, options include changing to a medication in the same class or in a different class. Augmenting treatment with a second medication is also reasonable, and augmentation with sustained-release bupropion may be more effective and better tolerated than treatment augmentation with buspirone.
Patients who receive concomitant psychotherapy with antidepressant therapy are more likely to continue medical therapy, and this combination of therapy appears more effective than medication alone. Cognitive behavioral therapy and interpersonal therapy have been demonstrated to be as effective as antidepressant medical therapy.
Patients treated with antidepressants should be monitored for suicidality. The risk for suicide may be highest during the first month of antidepressant treatment.
Posted by seldomseen on March 25, 2009, at 21:00:04
In reply to What your docs and nurses and phamacists learning, posted by Phillipa on March 25, 2009, at 18:54:19
This all sounds quite reasonable to me, except for two things.
First, I think a primary care physician should refer a patient to a psychiatrist after the first failure in treatment with an SSRI. Even with reviews and CMEs such as these, I do not think PCPs have the training to handle these cases.
Second, although I will admit that I scanned the post, I did not see any mention as to how the diagnosis of depression is made by the PCP. As has been noted multiple times on this board, depression may simply be a symptom of an underlying disease process. The PCP, I think, should not immediately prescribe anti-depressants without a complete examination. If a diagnosis of depression is made, then the first phase of treatment should begin.
Just my opinion as a patient.
Seldom.
Posted by Phillipa on March 25, 2009, at 21:04:07
In reply to Re: What your docs and nurses and phamacists learning » Phillipa, posted by seldomseen on March 25, 2009, at 21:00:04
Seldom I agree hence the purpose of posting the study. If this test is an indication of what they need to know as part of keeping license then I feel it's sad. Love Phillipa ps took about two minutes to read and pass the test. Ridiculous to me.
This is the end of the thread.
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