Treatment Strategy Hierarchy

Safety: stabilize suicidality, homocidality, self harm, acting out

Psychosis: treat aggressively, rule out delirium, substance inducedSubstance Induced: treat with detox, benzos,

usually resolves in 2-3 daysMania: aggressive antimanic treatment; remember

SGAs work quickly, AEDs take > 1 weekDepression: 1 year commitment

How to Choose Antidepressants• SSRIs• Early or initial

depression• Comorbid anxiety

disorders• Menstrual or

peripartum symptoms• Obsessive- compulsive

symptoms

• SNRIs or NE agents• Pain• ADHD• Smoking• Treatment failure or

resistance• Atypical symptoms

How to Choose Antidepressants

• Antipsychotics/ mood stabilizers

• Psychotic features• Melancholia• Mania or mixed state• Suiciality• Treatment resistance• Rapid stabilization

• Dopamine Agents

• Treatment resistance• Melancholia• Cognitive disorders• ADHD• Certain comorbid

medical conditions

Use of Novel Agents

• Viibryd: SSRI “poopout”, activation, SNRI intolerance

• Fetzima: Increased need for NE: pain, fatigue, especially sleep disorders, rheumatologic disorders, is enantiomer of Savella

• Brintellix: geriatics, cognitive disorders, treatment failure

• Latuda: bipolar depression, psychosis, metabolic syndrome with other SGAs

Special Considerations• Food: Viibryd and Latuda require 350 kcal for

absorption.• Activation: Viibryd AM, Latuda and Saphris PM, • Drug interactions: half Wellbutrin dose with

Brintellix, no triptans with Brintellix• Pain: Fetzima is off label if used only for this• Pregnancy: Latuda is category B . All others are C.• General: nausea is the primary TRE for all agents.

Its worth taking time to enhance compliance. Anti nausea agents can be helpful.

Comorbidities• Comorbidities are common with mood disorders.• Caveats:– Nothing good happens at 3 am. Stabilize sleep– When in doubt, stabilize it out. SGAs and other meds

can be used as a stop gap while waiting for antidepressant effects.

– No haldol unless in the ICU. Use IM Geodon or Zyprexa

– Benzos, opiates and sedatives will likely worsen depression and should be minimized.

– OSA, GERD and diabetes must be stabilized to get remission