Anxiety/Depression¶
Lauren Waskowicz
Background¶
- Anxiety disorders: spectrum of disorders characterized by excessive fear, anticipatory anxiety of future threat, or avoidance behaviors
- Includes generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, specific phobias, substance-induced anxiety disorder
- Mood disorders:
- Include major depressive disorder (MDD), bipolar disorder (BPD), seasonal affective disorder, dysthymia
Presentation¶
- MDD: 2+ weeks of ≧ 5/9 SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicide), or PHQ-2 screen >2 / PHQ-9 score > 4
- GAD: 6+ months of anxiety and associated restlessness, fatigue, impaired concentration, sleep disturbances (use GAD-7 tool to assess)
Evaluation¶
- Screen for personal and family history of substance use disorders (often comorbid with mood disorders)
- Screen for family members with MDD/GAD, and if positive, which SSRIs have worked (genetic component of responsiveness)
- Screen for suicidal ideation (“Have you ever had thoughts about wanting to be dead? Not wanting to wake up?”)
- If “yes,” assess for active/passive (“in the past week, have you had any actual thoughts of killing yourself?”), plan/intent (“do you have a plan to kill yourself and do you have intent to act on them?”)
- Ask about prior psychiatric hospitalizations
- Ask about firearms in the house
- Screen for periods of mania (“have you ever felt like you have needed <3-4 hours a night of sleep?”) as this is a contraindication for SSRIs (below)
- PHQ-9 > 4 abnormal, >9 consider therapy ± pharmacotherapy
Management¶
- No psychotherapy offered through VUMC. Counsel to call insurance customer service and ask for in-network counselors accepting new pts. Can also recommend psychology today website (https://www.psychologytoday.com/us) for assistance in finding therapy based on insurance coverage (.PSYCHTODAY)
- EPIC dot phrase for Nashville therapists (who have accepted OHO pts in the past): .CTLPSY-CHRESOURCES and .LRWPSYCHCOMMUNITY
- Persons in crisis: for pts expressing active suicidal ideation with intent, can refer to:
- Centerstone (TN crisis line): see directory
- Mental Health Cooperative (emergency line): see directory
- Safety planning via removal of firearms from home
| Medication | Dosing (Ramp) | Notes | Side Effects | Contraindications |
|---|---|---|---|---|
| SSRIs (First Line for Initiation) |
Fluoxetine (Prozac) 10mg QD x2wk 20mg QD x2 wk assess at 6wk fu Uptitrate to 40mg, 60mg, 80mg (max dose) |
No discontinuation syndrome (4–6 day half-life, helpful if pt struggles with adherence) | *GI upset (usually recedes within weeks of initiation) *Sexual dysfunction (delayed ejaculation, decreased libido) |
*History of mania (can trigger manic episode) *Black box suicidal ideation warning (counsel prior to initiation) |
| Sertraline (Zoloft) 25mg QD x2wk 50mg QD x2wk assess at 6wk fu Uptitrate to 100mg, 150mg, 200mg (max dose) QD |
~36 hr half life | |||
| Escitalopram (Lexapro) 10mg QD x2 wk assess at 6wk fu Uptitrate to 20mg, 30mg (max dose) QD |
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| SNRIs ALTERNATIVE AGENT for comorbid neuropathy and chronic pain syndrome |
Duloxetine (Cymbalta) 20mg QD x2 wk 30mg QD x2 wk 60mg QD 60mg BID (max dose) |
Average therapeutic dose for GAD (120mg QD) vs fibromyalgia or chronic pain (60mg QD) | Hepatic dysfunction | |
| TCAs ALTERNATIVE AGENT for comorbid insomnia and neuropathy |
Nortriptyline (Pamelor) 25mg QD x2wk 50mg QD x 2wk 75mg QD x2wk 100 mg QD x2wk; 150mg (max dose) QD |
Nortriptyline is least sedating of TCAs. Not first line due to side effects | Anticholinergic: constipation, dry mouth, orthostatic hypotension | Concurrent MAOI (including linezolid) |
| ADDITIONAL AGENT for 1) sexual dysfunction or 2) mood-predominant symptoms | Bupropion (Wellbutrin) 150mg SR qAM x2wk 150mg SR BID x2wk 300mg XL 24hr |
*Seizure disorder *Eating disorder history |
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| ADDITIONAL AGENT for anxiety predominant symptoms | Buspirone (Buspar) 15mg QD increase by 5mg QD every week, max dose 60mg QD |
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| Hydroxyzine (Atarax) 25 to 50 mg QID PRN, can increase as tolerated, max single dose: 100 mg and max daily dose: 400 mg |
For insomnia associated with anxiety, administer at bedtime | Anticholinergic: dry mouth, drowsiness, QT prolongation | *Avoid in geriatric population given anticholinergic effects *Prolonged QT |