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8/5/18
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EVALUATION & TREATMENT OF DEPRESSION & ANXIETY IN PRIMARY CAREMIKAYLE “MIKI” DURANT, MSN, APRN, PMHNP-BC
SEPTEMBER 8, 2018
PEDIATRIC SCREENING: DEPRESSION
• Pediatric – Mood and Feelings Questionnaire (MFQ)
• Teen (11 and over) – Columbia DISC Depression Scale
• Children – Center for Epidemiological Studies Depression Scale for Children (CES-DC)
• Perinatal – Perinatal Anxiety Screening Scale (PASS)
ADULT/GERIATRIC SCREENING: DEPRESSION
• Montgomery-Asberg Depression Scale (MADRS)
• Hamilton Depression Rating Scale (HAM-D)
• Beck Depression Inventory (BDI)
• Patient Health Questionnaire (PHQ-9)
SCREENING: ANXIETY
• Pedi – Screen for Child Anxiety Related Disorders (SCARED)
• Pedi & Adult – Hamilton Anxiety Rating Scale (HAM-A)
• Adult – State-Trait Anxiety Inventory (STAI)
• 17 and older – Beck Anxiety Inventory
• Hospital Anxiety and Depression Scale (HADS)
SCREENING: BASIC LABORATORY
• UA
• UDS
• hCG
• CMP
• CBC
• TSH
• Vitamin D
DSM-5 CRITERIA FOR DEPRESSION (P. 160-168)
• 5 or more causing social, occupational, educational problems – not drug/medical related
• Depressed mood most of every day
• Markedly diminished interest in once pleasurable activities
• Significant weight gain or loss
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation
• Feeling worthless, excessive guilt
• Poor concentration
• Recurrent thoughts of death or suicidal ideation
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PHARMACOLOGICAL TREATMENTS: DEPRESSION
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• fluoxetine Prozac max 80mg – 6 years old
• sertraline Zoloft max 200mg – 6 years old
• citalopram Celexa max 40mg – 7 years old
• escitalopram Lexapro max 20mg – 7 years old
• paroxetine Paxil max 50mg – adults
PHARMACOLOGICAL TREATMENTS: DEPRESSION
• Selective Norepinephrine Reuptake Inhibitors (SNRIs)
• desvenlafaxin Pristiq max 100mg – adults
• duloxetine Cymbalta max 120mg – 7 years old
• levomilnacipran Fetzima max 120mg – adults
• venlafaxine Effexor XR max 225mg – 7 years old
PHARMACOLOGICAL TREATMENTS: DEPRESSION
• Novel Antidepressants
• vilazodone Viibryd max 40mg – adults
• vortioxetine Trintellix max 20mg – adults
• Other
• buproprion Wellbutrin XL max 300mg – 12 years old
• mirtazapine Remeron max 45mg – 7 years old
• trazodone Desyrel, Oleptro ER max 400-600mg – adults
BLACK BOX WARNING
• Suicidality and SSRIs
• risk in children/adolescents with major depressive or other psychiatric disorders
• weigh risk vs. benefit
• observe all patients for clinical worsening, suicidality, or unusual behavior changes
• advise families and caregivers of need for close observation and communication w/ prescriber
DSM-5 CRITERIA FOR ANXIETY (PAGES 189-264)COMMONLY TREATED
• Social Anxiety Disorder
• Panic Disorder
• Agoraphobia
• Generalized Anxiety Disorder
• Obsessive-Compulsive Disorder
• Unspecified Anxiety Disorder
DSM-5 CRITERIA FOR ANXIETY (PAGES 189-264)
• Separation Anxiety Disorder
• Selective Mutism
• Specific Phobia
• Body Dysmorphic Disorder
• Hoarding Disorder
• Trichotillomania
• Excoriation Disorder
• Substance/Medication-Induced Anxiety Disorder
• Anxiety Disorder due to Another Medical Condition
• Other Specified Anxiety Disorder
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PHARMACOLOGICAL TREATMENTS: ANXIETY
• Benzodiazepines
• alprazolam Xanax, Xanax XR – short & long acting; max 9mg – 7 years old
• chlordiazepoxide Librium – longer acting; max 100mg – adults
• clonazepam Klonopin – longer acting; max 15mg – adults
• diazepam Valium – medium acting; max 40mg – 6 months
• lorazepam Ativan – short acting; max 10mg – children
BLACK BOX WARNING
• Risks from Concomitant Opioid Use
• concomitant benzodiazepine use with opioids may result in profound sedation, respiratory depression, coma, and death
• reserve concomitant use for patients with no other treatment alternatives
• limit to minimum required dosage and duration
• monitor for signs and symptoms of respiratory depression and sedation
PHARMACOLOGICAL TREATMENTS: ANXIETY
• Non-benzodiazepines
• buspirone BuSpar max 60mg – 6 years old
• hydroxyzine HCL Atarax 400mg – 6 years old
• hydroxyzine pamoate Vistaril 400mg – 6 years old
PHARMACOLOGICAL TREATMENTS: ANXIETY
• SSRIs/SNRIs
• Prozac – OCD ≥ 7, PD, PTSD ≥ 7, SAD ≥ 5
• Zoloft – OCD ≥ 6, PD, PTSD, SAD
• Celexa – OCD ≥ 7, GAD ≥ 7
• Lexapro – SAD ≥ 10, GAD
• Paxil – OCD ≥ 7, PD, PTSD, SAD ≥ 8, GAD
• Cymbalta – GAD ≥ 7
• Effexor XR – GAD ≥ 7
PRESCRIPTION MONITORING PROGRAM
• September 1, 2019
• H.B. 2561
• NPs – monitor controlled substances prescribing patterns
PHARMACOLOGICAL TREATMENTS: COMMON ADVERSE EFFECTS
• Diarrhea or constipation
• Sedation or agitation
• Hypersomnia or insomnia
• Excessive yawning
• Excessive Sweating
• Nausea, headache, dry mouth
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PHARMACOLOGICAL TREATMENTS: CONTRAINDICATIONS
• Wellbutrin and seizure disorders
• Cymbalta without monitoring liver enzymes
• SSRI/SNRI to treat mania or bipolar disorder
• Lithium and poor kidney function
• Alcohol or other CNS depressants mixed with benzodiazepines
PSYCHIATRIC REFERRALS
WHEN TO REFER• Suicidal or homicidal patient with plan,
intent, and/or access
• Anxiety or mania?
• Spectrum of schizophrenia symptoms
• Personality disorder
WHERE TO REFER• Start with office manager or
collaborating physician – you are not alone
• Local Mental Health Authority
• Local PMHNP or Psychiatrist
• Local law enforcement agency
INTERACTIVE PARTICIPATION
SCENARIO 1
• What screen do you use?
• Is she suffering from MDD?
• What treatments might you consider?
SCENARIO 2
• What is his most likely diagnosis?
• What short acting benzodiazepine do you prescribe?
• What SSRI do you prescribe?
REFERENCES
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
• Burka, S. D., Van Cleve, S. N., Shafer, S. ,& Barkin, J. L., (2014). Integration of pediatric mental health care: An evidence-based workshop for primary care providers. Journal of Pediatric Health Care, 28(1), 23-34. doi:10.1016/j.pedhc.2012.10.006
• Dihigo, S. K. (2014). Use of screening tools for depression in adolescents: An evidence-based systematic review. Women's Healthcare: A Clinical Journal For Nps, 2(2), 23-30.
• McGough, P. M., Bauer, A. M., Collins, L., & Dugdale, D. C. (2016). Integrating behavioral health into primary care. Population Health Management, 19(2), 81-87. doi:10.1089/pop.2015.0039
• Somerville, S., Dedman, K., Hagan, R., Oxnam, E., Wettinger, M., Byrne, S., & ... Page, A. (2014). The Perinatal Anxiety Screening Scale: development and preliminary validation. Archives Of Women's Mental Health, 17(5), 443-454. doi:10.1007/s00737-014-0425-8
• Texas Sunset Advisory Commission. (2017). Texas board of nursing (BON). Retrieved from https://www.sunset.texas.gov/reviews-and-reports/agencies/texas-board-nursing-bon