#35 Depression: MDD with DJ MMC

April 17, 2017 | By Matthew Watto, MD

Master the management of major depressive disorder (MDD) with clinical pearls from Dr. Marius Marcel Commodore, Associate Professor of Clinical Medicine and Psychiatry from Temple University Hospital. We cover diagnosis, patient counseling, choice of agent, dose titration, augmentation…and DJ names?

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Take home points:

1. Screening with PHQ2 is important. Ask: Do you feel depressed? Do you feel anhedonic?
2. Antidepressants do work! It takes time and lots of expectation management.
3. Early referral to psychiatry is important to prevent lag in appropriate care.
4. Measure depression before and during treatment to track progress.
5. Encourage openness in patients on treatment for depression. It normalizes depression and helps fight the stigma.

Clinical Pearls:

1. Screening for medical conditions like thyroid disease and adrenal insufficiency tend to be low yield (expert opinion, Dr. Commodore)
2. Dr. Stuart Brigham recommends ferritin and iron panel for all patients with mood disorder (expert opinion, Dr. Stuart Brigham)
3. PHQ9 or Beck Depression Inventory (BDI) are quick. Repeat at future visit to check for response, or remission. Geriatric depression scale preferred for patients greater than 70 years old.
4. Nonpharmacologic therapy: sleep hygiene, and activity as tolerated (“planned outings”) are effective and FREE!
5. Psychotherapy is equivalent to medication for mild to moderate depression. Caveat = in practice good therapy is hard to find and $$$. Online CBT and telepsychiatry may be available in given areas.
6. Screen for bipolar disorder with mood disorders questionnaire prior to initiation of therapy for MDD. High negative predictive value.
7. Medications: Must stress prolonged time for onset of action. Encourage patients not to QUIT medication. Start LOW and go SLOW. Follow up by phone in two weeks and in person in one month to ensure compliance. Goal is a trial of at least 6-8 weeks on a good dose of an agent (ideally 12 weeks).
8. Choice of agent: Cost and side effect profile matter most. SSRIs are cheap and easily available. If prior success with a specific agent, then resume that agent.
9. First generation agents: tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs) no longer first line due to side effects and risk profile.
10. Second generation agents (SSRI, SNRI, mirtazapine, bupropion, trazodone) largely equal in efficacy.
11. Medications: Response to treatment = 50% decrease in depression scale (e.g. PHQ9 or BDI). Remission on the PHQ9 is a score of 5 or less.
12. Continuation of therapy: recommended for at least 9 months for first episode. In practice most patients prefer to taper off after 12 months.
13. Potential agents for augmentation (mirtazapine, bupropion, TCAs, aripiprazole, quetiapine).
14. Relapse rates: after one episode MDD = 50% at 5 years. If two episodes MDD = 70% at 5 years, and if three episodes MDD = nearly 100% at 5 years.
15. Suicide risk: Be direct in about suicide and be specific in asking about plans, protective factors (e.g. marriage, children, religion), and how often they consider suicide.
16. Mood disorders in colleagues: Look for changes in demeanor, lapses in their professional responsibility. Be direct and notify them of your concern.

Goal:
Listeners will develop a practical approach to the diagnosis and management of major depressive disorder in the primary care setting

Learning objectives:
By the end of this podcast listeners will:

1. Choose an appropriate screening tool for depression
2. Counsel patients on specifics of medication management including dose titration, treatment duration
3. Initiate therapy with second generation antidepressant and monitor patient response
4. Identify patients who may benefit from medication augmentation
5. Screen patients for suicidality
6. Screen patients for bipolar disorder
7. Recognize mood disorder in other health care providers

Disclosures:
Dr. Commodore reports no relevant financial disclosures.

Time Stamps
00:00 Intro
02:08 Rapid fire questions
11:04 Initial diagnosis and screening
13:06 Tools for diagnosis discussed
17:07 Shared decision making in choice of agent
19:40 Monitoring and follow up
21:51 Choice and comparison of agents
27:38 Augmentation and the STAR-D study
31:03 Quick recap
33:52 Cognitive behavior therapy
40:58 Medication titration and duration of therapy
45:18 Bipolar disorder screening
47:38 Screening for suicidality
49:58 Difficulty getting patients into specialty care
53:38 Mood disorders in health care providers
58:31 Listener Questions
60:48 Take home points
64:10 Outro

Links from the show:

1. 1984 (book) by George Orwell
2. PHQ9 Journal General Internal Medicine 2001
3. Beck Depression Inventory
4. Practice guideline for the treatment of patients with major depressive disorder, third edition. Guidelines.gov 27 Nov 2015
5. Implementing AHRQ Effective Health Care Reviews: Second-Generation Antidepressants for Depression. AAFP 2013. 27 Nov 2015
6. CO-MED Study. Am J Psychiatry 2011 Jul;168:7:689-701. PMID: 21536692
7. STAR*D Trial. Am J Psychiatry 2006 Nov;163(11):1905-17. PMID: 17074942
8. What Are the Implications of the STAR*D Trial for Primary Care? A Review and Synthesis. Prim Care Companion J Clin Psychiatry. 2008; 10(2): 91–96. PMCID: PMC2292446
9. Mood Disorders Questionnaire
10. Shared Decision Making in Chronic Depression from Mayo Clinic.org
11. Use of bupropion to enhance sexual performance in patient on SSRI BJU 2010