Michael Panzer, MD ThedaCare Behavioral Health DEPRESSION Michael Panzer, MD ThedaCare Behavioral Health

PEARLS SCREEN FOR BIPOLAR HIGH RECURRENCE RISK THERAPY LIFESTYLE

HOW WILL YOU APPLY THIS TALK TO YOUR PRACTICE?

SYMPTOMS OF DEPRESSION DEPRESSED MOOD OR PLEASURE CHANGE IN APPETITE / WEIGHT CHANGE IN SLEEP PSYCHOMOTOR CHANGE

…SYMPTOMS FATIGUE WORTHLESSNESS OR GUILT DECREASED CONCENTRATION MORBID THOUGHTS

…SYMPTOMS (NON-DSM) CRYING NEEDLESS WORRY IRRITABILITY WITHDRAWAL DIURNAL PATTERN

NATURAL HISTORY AGE IF GOES UNTREATED… SUICIDE BECOMES HARDER TO TREAT

RECURRENCE RISK 1 EPISODE: 50 % OLDER ONSET RESIDUAL SX RISKS FROM RECURRENCE

MDQ MOOD SLEEP PAINFUL CONSEQUENCES MANIA MDQ MOOD SLEEP PAINFUL CONSEQUENCES

ANTIDEPRESSANTS MAOIs TCAs SSRIs SNRIs

SSRIs fluoxetine paroxetine fluvoxamine citalopram sertraline escitalopram

SSRI STRATEGIES START LOW, GO SLOW PATIENCE DO NOT STOP SUDDENLY BROAD SPECTRUM

OTHER ANTIDEPRESSANTS MIRTAZAPINE NEFAZODONE VILAZODONE VORTIOXETINE

ANXIETY AND DEPRESSION EACH TENDS TO CAUSE THE OTHER USEFUL TO KNOW WHICH IS PRIMARY

DSM 5 ANXIETY FAREWELL: OCD, PTSD, ASD, OVERANXIOUS WELCOME: MUTISM SEPARATION ANXIETY

DSM 5 ANXIETY PANIC AND AGORAPHOBIA GENERALIZED ANXIETY SOCIAL ANXIETY DISORDER (OCD) PHOBIAS (PTSD, ASD)

BENZODIAZEPINES CLONAZEPAM 0.25-0.5 mg ALPRAZOLAM 0.5 mg LORAZEPAM 1.0 mg DIAZEPAM 5-10 mg

BENZODIAZEPINE RISKS DEPENDENCE ABUSE WITHDRAWAL PSYCHOMOTOR IMPAIRMENT COGNITION SEDATION

DOCUMENTATION – BZs driving alcohol collateral sources patient tolerance alternatives tried PDMP mad relatives

OTHER ANXIOLYTICS. HYDROXYZINE OTHER ANXIOLYTICS *HYDROXYZINE *BUSPIRONE GABAPENTIN PREGABALIN ATYPICALS? PROPRANOLOL *approved

LITHIUM Excellent stabilizer, some antidepressant effect Lowers the risk of suicide! (do not stop suddenly) Narrow therapeutic window, levels important Renal, thyroid, GI, tremor, thirst, weight Interactions (NSAIDS, diuretics, ACE inhibitors) Avoid dehydration TSH, creatinine, 12-hour level, (calcium)

LAMOTRIGINE (Lamictal) Anticonvulsant More antidepressant than antimanic Like an antidepressant that does not destabilize Well-tolerated (HA, rash) Slow No labs (+/- level) Interactions: valproic acid, CBZ, estrogen

QUETIAPINE (Seroquel) Atypical antipsychotic Robust antidepressant and antimanic activity Sleep / sedation, weight gain, metabolics EPS, TD, dizziness Baseline fasting labs, 3m and yearly, and discussion of metabolic effects

ARIPIPRAZOLE (Abilify) Atypical antipsychotic Unipolar depression (adjunct) Mania and mixed Nonapproved use for bipolar depression Some potential for sedation and weight gain EPS, TD, dizziness Baseline fasting labs, 3m and yearly, and discussion of metabolic effects

EXERCISE WORK FINANCES MEDICAL LIFE FACTORS EXERCISE WORK FINANCES MEDICAL

THERAPY CBT MINDFULNESS EXPOSURE MARITAL

DON’T DO TOO MUCH CONSIDER MAJOR STRESSORS CAREFUL ABOUT DOSES NOT TOO MANY MEDICATIONS CONSIDER YOUR LIMITS CONSULT