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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