Depression Cheat Sheet (DRAFT) by smray757

Escita­lopram

Good for side effect prone indivi­duals, geriatric patients, prominent co-morbid anxiety. More potent than citalopram with better side effect profile and lower risk for QTc prolon­gation. Fewest drug intera­ctions of all SSRI's, consider with polyph­armacy. Dose range 5-30mg daily.

Fluoxetine

Good for patients who struggle with missed doses due to long half life and active metabo­lites. Activating properties can combat lethargy and other neurov­ege­tative symptoms, and cause less weight gain. Caution in patients with anxiety and insomnia. Consid­erable inhibition at CYP2D6 and CYP3A4, therefore can legiti­mately increase levels of warfarin, tramadol, simvas­tatin, atorva­statin, beta blockers, alpraz­olam. No dose adjustment for renal impair­ment, lower dose by 50% in moderate to severe hepatic impair­ment. Dose range 10-80mg daily.

Fluvox­amine

Good for patients with OCD, co-morbid anxiety, and need for rapid onset of action. May also have less sexual dysfun­ction. Caution in IBS due to prominent GI side effects, disadv­antage of twice daily dosing. Consid­erable inhibition at CYP1A2 and CYP3A4, can reduce clearance of caffeine, alpraz­olam, simvas­tatin, atorva­statin. Smoking increases the drug clearance and lowers efficacy. Reduce dosage by 25% in renal impair­ment, 50% in moderate to severe hepatic impair­ment.

Bupropion

Good for patients with low energy­/mo­tiv­ation, co-morbid ADHD, tobacco use disorder. Also ideal for patients concerned about sexual dysfun­ction and weight gain. Not ideal with severe co-morbid anxiety, tic disorders, eating disorders, insomnia, or seizure disorder. XL formul­ation better tolerated in general. Limited drug intera­ctions, but do not combine with nicotine replac­ement therapy due to risk of hypert­ension. No dose adjustment necessary with renal impair­ment, for hepatic impairment maximum dose is 150mg XL every other day. Dose range for XL 150mg-­450mg.

MIrtaz­apine

Good for patients with insomnia, anxiety, appetite loss, nausea/GI issues. May have less associated sexual dysfun­ction, and have a faster onset of action. Not ideal in obesity, low energy­/fa­tigue, vulner­ability to orthos­tasis. Weight gain more common in women, occurs within first 6 weeks. Does not affect CYP450 system, minimal drug intera­ctions. Use with caution in hepatic and renal impair­ment, but no required dose adjust­ment. Dose range 7.5-45mg daily, dose at night. Sedation occurs mostly at lower doses.

Mirtaz­apine

Can be added to SSRI or SNRI to potentiate antide­pre­ssant effect, improve insomnia, anxiety or appetite. Tends to be more sedating at lower doses (7.5 and 15mg)

Aripip­razole

Can be added to SSRI or SNRI in cases with low energy­/mo­tiv­ation, prominent intrusive or obsessive thinking patterns, and agitation. Has the best evidence of all augmen­tation strate­gies. Also a good choice in patients concerned about weight gain. Effective dose range is 2-10mg daily. Common side effects include dizziness, consti­pation, nausea, and akathisia. No dose adjustment necessary for renal or hepatic impair­ment. Fluoxe­tine, fluvox­amine, and paroxetine will increase plasma levels. Check BMI, lipids, A1c at 1,3, and 6 months then yearly.

Lithium

Can be added to SSRI or SNRI in cases with prominent emotional dysreg­ula­tion, chronic suicidal thinking, anxiety, obsess­ive­/in­trusive thinking patterns. Used at low doses as adjunct to antide­pre­ssant, start at 150mg PO QHS and titrate up to 300-600mg PO QHS. Check level 5-7 days after initia­tion, and after each dosage increase. Maintain lower blood levels, generally 0.6-0.8. Levels should be checked at 12 hours after last dose to obtain true trough. When stable dose is reached switch to CR formul­ation and dose at night. Common side effects include nausea, mild tremor, sedation, weight gain, polyuria, polydi­psia, and hypoth­yro­idism. Not recomm­ended in renal insuff­ici­ency, no dose adjustment necessary for hepatic insuff­ici­ency. NSAIDs, thiazide diuretics, COX-2 inhibi­tors, ACE inhibi­tors, calcium channel blockers can all increase lithium levels. Monitor levels during GI illness or any condition that involves fluid shifts or dehydr­ation. Check BMP, TSH at baseline then at 1,3, and 6 months.

Modafinil

Can be added to SSRI or SNRI in cases with co-morbid OSA, fatigue, cognitive diffic­ulties, poor sleep patterns due to shift work. Not ideal in prominent anxiety, insomnia, hypert­ension. Common side effects include headache, nausea, insomnia, anxiety, palpit­ations, appetite loss. May increase levels of propra­nolol, through CYP2C19 inhibi­tion, reduces levels of warfarin, contra­cep­tives. Effect is inhibited by prazosin or other alpha 1 blockers. Less abuse potential compared with stimul­ants. Dose range is 100-200mg daily. Dose reduction of 50% in both renal and hepatic impair­ment.

Methyl­phe­nidate

Can be added to SSRI or SNRI in cases with severe fatigue and lack of energy­/mo­tiv­ation. Safe and well tolerated in geriatric depression or post stroke depres­sion, generally doses are low 5-20mg daily. Not ideal for patients with substance use disorders, anxiety, insomnia, loss of appetite. Safer and better tolerated than amphet­amine prepar­ations. Limited drug intera­ctions, no dose adjustment necessary for renal or hepatic impair­ment. Caution in patients with coronary artery disease, monitor BP at each visit.