Anxiety/Depression

Aseem Utrankar

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). PHQ is screening not diagnostic, but PHQ9 score 10+ has 85% sensitivity and specificity for MDD. 
  • GAD: 6+ months of anxiety and associated restlessness, fatigue, impaired concentration, sleep disturbances (use GAD-7 tool to assess) 
  • Adjustment disorder: clinically significant emotional or behavioral symptoms in response to a stressor within 3mo of symptom onset, and with symptoms lasting less than 6mo after the stressor has ended

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?”) 
  • CSSR scale for more structured assessment of suicide risk 
  • 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 5-10 mild, 10-14 moderate, 15-19 moderately severe, 20+ severe; >9 consider therapy +/- pharmacotherapy

Management 

  • Generally, no psychotherapy covered 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 (.PSYCHTODAY). Dot-phrase for Nashville community resources including therapy, ADHD testing (.LRWPSYCHCOMMUNITY) 
  • Employee Assistance Programs are workplace based programs offering free and typically quick to access psychotherapy 
  • Persons in crisis: for pts expressing active suicidal ideation with intent, can refer to: 
    • Centerstone (TN crisis line): (800) 681-7444 
    • Mental Health Cooperative (emergency line): (615) 726-0125 
    • VUMC Psychiatric Assessment Services: 615-327-7000 
    • Safety planning via removal of access to firearms

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
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) moodpredominant symptoms

Bupropion (Wellbutrin)

150mg SR qAM x2wk

150mg SR BID x2wk

300mg XL 24hr

seizure disorder

eating disorder history
ADDITIONAL AGENT for anxietypredominant symptoms

Busiprone (Buspar)

15mg QD

increase by 5mg QD every week, max dose 60mg QD

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 Anticholinergi c: dry mouth, drowsiness, QT prolongation

Avoid in geriatric population given anticholinergi c effects

Prolonged QT
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