Algorithm for Initiating Antidepressant Therapy in Depression

Depressed For mild depression specific psychological

Moderate to Severe depression treatments are preferable to antidepressants,
(PHQ 15 or more) Mood
PHQ <15 unless history of previous
depressive episodes
Refer for Assess within 2 weeks.
psychotherapy if Offer Antidepressant
patient preference or Medication Antidepressant
add cognitive
behavioural office Treatment Appropriate
skills to antidepressant
medication
Under 18s: Fluoxetine

Choice of Antidepressant
Consider: Peripartum: See Family Practice
Guide section 7 or call Motherisk at
 Cost and acceptability to patient 416-813-6780 www.motherisk.org
 Tolerability and adverse effects to a particular drug
 Likely side effect profile/potential interactions Bipolar: Mood stabilizer +/-
antidepressant
 Risk of suicide/accidental overdose
 Consider using previously effective drug Post MI/Acute Coronary Syndrome
Citalopram 20mg or Sertraline 50-100mg
daily

First Line : SSRI,SNRI or

Bupropion No response after 4-6weeks of
therapeutic dose:
See Family Practice Guide 3.31 -Switch to another first line
Assess within 2 weeks and then every
agent
2-4 weeks (6 weeks in elderly) for 3
-Consider switching classes
months
-Re-evaluate diagnosis
If increased risk of suicide or younger
-Reassess compliance
than 30 years, see after 1 week and
-Reassess comorbidity
frequently thereafter.
Adequate trials of 2
Partial Response Choices medications not
Family Practice Guide 3.30 Not tolerated effective or not
–postpone switch until 4-6 wks tolerated
-optimize dose Lower Ineffective
-Emergent situation
-augmentation with Lithium, T3, dose., developing (psychosis,
or atypical antipsychotic Switch to a
-switch to another class different
suicidal intent)
Second line agent: -Diagnostic dilemma
-combine SSRI+ SNRI, class Tricyclic
Mirtazapine, or Bupropion
antidepressant
-Significant co-
morbidity
Drug effective and
tolerated at any stage

Continue on same dose:

 For min. 6 months after return to normal functioning/mood Refer :
if 1st episode (12 months in elderly) and then review need Mental Health Services or
for continued treatment considering number of previous
episodes, severity of initial illness, presence of residual Emergency services if
symptoms and concurrent psychosocial difficulties. If 2 or patient in imminent danger
more episodes treat for at least 2 years to self or other
 Use gradual stepwise reduction of dose to discontinue –
may not be necessary for Fluoxetine.
May 2009
 MAJOR DEPRESSIVE DISORDER

Not all medications listed are eligible for coverage under the No-Charge Psychiatric Medication Program (Plan G).
Coverage information is provided on the BC PharmaCare website at www.health.gov.bc.ca/pharme/outgoing/plangtable.html.

FA M I LY P H YS I C I A N G U I D E | PHARMACOLOGICAL INTERVENTION 3.31

APPENDIX 2: WOMEN’S MENTAL HEALTH ISSUES

Detailed information on the specific application of these treatment modalities in the

perinatal period is in the (1) Best Practices Guidelines relating to Reproductive
Mental Health, and (2) Self-Care Program for Women with postpartum depression &
anxiety (see Resources). See also the section on non-pharmacological therapies in
the Guide.

Pharmacotherapy in the Perinatal Period

Practice Issues: Antidepressants in Pregnancy and Postpartum

■ Sustaining maternal mental health throughout pregnancy is the key to ensuring
an optimum outcome for the baby.
■ As yet, there is little evidence for the efficacy of psychotherapy in the treatment
of moderate to severe depression in pregnant, depressed women.
■ Resolution of symptoms for women in this category is best achieved, at present,
with antidepressant medications.
■ Women with severe depression and with a prior history of depression can be
treated with a combination of antidepressant medication and psychotherapy.
■ To date, existing evidence suggests that the most commonly used antidepressant
medications, such as SSRIs (e.g., Prozac, Paxil, Zoloft, Luvox and Celexa) and
SNRIs (e.g., Effexor), have not been associated with major birth defects.
■ There is increasing concern regarding transient neonatal adaptation symptoms
following prenatal exposure.
■ This has led the Health Canada (see Health Canada Advisory below) and the US
Food and Drug Administration (FDA) to issue warnings regarding third-trimester
SSRI and SNRI use for treating depression during pregnancy.
■ The recent concern over the warnings by Health Canada and the US FDA
regarding infants exposed to antidepressants in the third trimester, has lead to a
clinical dilemma for treating physicians. The evidence for these warnings is:
– based on case reports and retrospective data.
– the number of cases studied tends to be small, particularly with newer
anti-depressants
■ In addition, the presence/absence of symptoms observed in neonates are
governed by a complex set of factors including:
– prematurity
– maternal mental and physical health
– use of concomitant substances (e.g., alcohol, cigarettes)
– polypharmacy
■ Characteristics of this Neonatal Poor Adaptation Syndrome include:
– transient course in the infant
– resolution within the first few days of life
– no evidence of long-term consequences in the children.
– the use of multiple psychotropic medications during pregnancy with an
SSRI appears to increase the risk of these symptoms

Neonatal Management Issues

■ An infant can be identified as being at risk for transient Neonatal Poor
Adaptation Syndrome if the mother is:
– taking a high dose of any antidepressant medication
– on more than one medication
– if the woman is mentally ill and/or under-treated

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 APPENDIX 2: WOMEN’S MENTAL HEALTH ISSUES

■ The infant’s behaviour should be monitored closely :

– by nursing and medical staff
– if there are signs of abnormal Central Nervous System (CNS) behaviour, avoid
early discharge and consider a differential diagnosis
– obtain infant drug levels if possible where a diagnosis remains unclear
■ Supportive neonatal care of symptomatic infants can be provided by using
the following approach:
– provide low level stimulation
– support breastfeeding
– provide supportive measures where appropriate
– follow symptoms closely
■ Ensure long-term follow-up for mother and infant.

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 Pharmacotherapy in the Perinatal Period: Specific Medications

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 Pharmacotherapy in the Perinatal Period: Specific Medications

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 Pharmacotherapy in the Perinatal Period: Specific Medications

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 Pharmacotherapy in the Perinatal Period: Specific Medications

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 Pharmacotherapy in the Perinatal Period: Specific Medications

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 MAJOR DEPRESSIVE DISORDER

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FA M I LY P H YS I C I A N G U I D E | A D D R E S S I N G S U I C I DA L R I S K page 2 of 6 3.73
MAJOR DEPRESSIVE DISORDER

Bipolar Disorder
Generally, initiate a mood stabilizer on admission with mania, hypomania,
or bipolar depression.

■ Discontinue antipsychotic typically six months after there has been a

good response.
■ Maintain on a mood stabilizer.
■ A combination of a mood stabilizer and a very low dose of an antipsychotic
is an option for treating refractory bipolar disorder.

FA M I LY P H YS I C I A N G U I D E | PHARMACOLOGICAL INTERVENTION 3.33