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*Antidepressant trial of adequate dose/duration is 4-6 weeks at FDA approved maximum dosage or maximum tolerated dose with minimum 80% Meets DSM-IV criteria for Major Depressive Disorder or severe Dysthymia Psychotherapy should be the initial treatment of choice and should be continued throughout treatment even if drug therapy is started.
Fluoxetine 20 – 60 mg/day for 4-6 weeks* Switch to alternative formulary SSRI not tried above. Citalopram 20 – 40mg/day or Sertraline Switch to alternative formulary antidepressant with different mechanism of action. Venlafaxine 37.5 - 225mg/day or Bupropion XL 150 - 300 mg/day for Switch to alternative formulary antidepressant not tried above. Venlafaxine or Bupropion XL for 4- Begin combination therapy. Venlafaxine or Bupropion XL plus SSRI for 4-6 weeks*
Continue combination antidepressant therapy from above plus Lithium or Lamotrigine for 4-6 weeks*
Consider therapy with antidepressant with best response plus formulary atypical antipsychotic for 4-6 weeks*
Reconsider diagnosis and consider psychopharmacology consultation Prepared By The Texas Youth Commission and Reviewed By The Correctional Managed Care Pharmacy & Therapeutics Committee. October 2001, revised 5/12/02, 2/25/04, 3/1/06. Revised by Youth Services Pharmacy & Therapeutics Committee 7/10. (note: original pathway developed by TDCJ Pharmacy & Therapeutics Committee 4/98, revised 7/98 then as above by TYC) Medication Selection
Patients should be evaluated for use of formulary agents whenever possible. Practitioners should consider past history of response, contraindications, co-morbidities, medication compliance, and potential for adverse effects and/or drug-drug interactions when making treatment decisions. When medications are changed, patients should be monitored more closely for signs of worsening symptoms and adverse effects.
Suicidality in Children and Adolescents
Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of any antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Bupropion General Information
The dosing strategy suggested for bupropion is 3mg/kg/day by the end of the first week and then titrated to 6mg/kg/day or 300mg/day by week3, whichever is less. It may take as long as 4 weeks to observe maximum effectiveness with bupropion. Bupropion XL is recommended for convenience of use because it requires less frequent dosing.
Lithium General Information
Therapeutic effects of lithium are seen 10-14 days after a therapeutic level has been achieved. It may take up to 6 weeks to see full effects of a given dosage. Laboratory measures and serum lithium levels should be reassessed every six months during maintenance treatment. Levels should be drawn 5-10 days (or more often if clinically indicated) after a dosage change, with the addition or deletion of drugs that increase or decrease lithium renal clearance (e.g., ACE inhibitors, calcium channel blockers, diuretics, NSAIDs, SSRIs, theophylline) or if there is a change in renal function. The lithium serum level should be obtained immediately before the next dose and at least 12 hours after the last dose. A therapeutic serum level is 0.9 to 1.3 mEq/L.
Common side effects: sedation, thirst, urinary frequency
Other side effects: hypothyroid, confusion, toxicity, acne, increased WBC’s
Table 1: Frequency of Lithium Monitoring
Parameter
Baseline
Every 6 Months
*Providers should consider obtaining an EKG at baseline and periodically when there is a personal or family history of Lamotrigine General Information
Lamotrigine is a third line agent that may be used if a patient fails to respond to an adequate trial of two formulary SSRIs, venlafaxine, bupropion XL, and a combination of antidepressants. Its use is reserved for patients with treatment resistant depression and requires non-formulary approval for use. The dose of lamotrigine must be titrated to minimize the risk of severe rash. Serious skin reactions are more likely to occur when starting therapy or following an interruption in therapy within the first 2 to 8 weeks of therapy. Children between the ages of 2 to 16 have a higher risk of experiencing serious skin reactions. If an interruption in therapy for a period of ≥ 5 days (5 half-lives) occurs, it is recommended that the dose be titrated again. Therapy should be discontinued at the first sign of rash unless the rash has been clearly identified as not drug-related. Starting Dose:
• 25mg daily for 2 weeks, then 50mg daily for 2 weeks, then 100mg daily for 1 week, then up to
• Co-administration with enzyme-inducing medications (e.g., carbamazepine, phenytoin, primidone) - 50mg once daily for 2 weeks, then 100mg once daily for 2 weeks, then up to 100mg twice daily. Higher doses may be used to achieve levels of 4-18 mcg/mL • Co-administration with enzyme-inhibiting medications (e.g., divalproex) – 25mg every other day for 2 weeks, then 25mg once daily for 2 weeks, then 50mg once daily for 1 week, then up to 100mg daily.
Serious side effects: Rash and Stevens Johnson Syndrome
Extreme caution: Extreme caution should be taken in combination with Valproate by using one
half the starting dose and monitoring levels.
Formulary agents – Practitioners may prescribe any agent on the formulary without restrictions
based on patient assessment and clinical judgment.
Table 2: Formulary Agents
Drug Class
Generic Name
Brand Name
Strength
*Not recommended as first line or second line therapy for treatment of depression in children or adolescents
Monitoring Parameters for Antipsychotics
Table 3: Metabolic and Endocrine Monitoring Guidelines for Antipsychotic
Agents in Children and Adolescents
Parameter & Frequency
Baseline
Annually
Providers should consider obtaining any of the laboratories listed above more frequently if clinically indicated.
Providers should consider obtaining an EKG at baseline and periodically when there is a personal or family history of cardiovascular disease.
Providers should consider obtaining Prolactin at baseline and periodically when there is a is a history of galactorrhea, amenorrhea, or gynecomastia Table 4: Adverse Effect Monitoring
Assessment
Baseline
Follow-up
(Abnormal Involuntary Movement Scale)•Acute EPS - Akathisia•Tardive Dyskinesia BRIEF PSYCHIATRIC RATING SCALE (BPRS)
Instructions for the Clinician
Background:
The Brief Psychiatric Rating Scale (BPRS) is a widely used instrument for assessing psychopathology at baseline and longitudinally as an outcome measurement when treatment is introduced. The BPRS is a scale measuring positive symptoms, general psychopathology and affective symptoms. It has proven particularly valuable for documenting the efficacy of treatment in patients who have moderate to severe psychopathology. The BPRS has been well validated in the clinical literature and is reportedly the most studied psychometric instrument currently in use. The BPRS should be administered by a clinician who is knowledgeable concerning psychiatric disorders and is able to interpret the constructs used in the assessment. The individual's behavior over the previous 2-3 days should also be considered and can be reported by the patient's caregivers or teachers. It should be utilized at baseline and then at each visit as long as the patient is prescribed a psychotropic medication. The BPRS utilized in the electronic medical record (EMR) consists of a range of 23 symptom constructs covering a broad array of potential psychopathology. The assessment typically takes 10-20 minutes or less for the interview and scoring. Instructions for Use and Scoring:
Each item is rated on a seven-point scale (1=not present to 7=extremely severe). Zero (0) is entered if the item is not assessed. The scores of the 23 items should be summed and recorded. The total score should be compared to the total score from one evaluation to the next as a measure of response to treatment. In addition, a single subscale (symptom) or cluster of subscales (e.g., grandiosity, elevated mood, excitement, distractibility) can be followed over time.
Brief Psychiatric Rating Scale (BPRS)
Patient Number __________ Date_______________ Enter the score for the term that best describes the patient’s condition.
0 = Not assessed, 1 = Not present, 2 = Very mild, 3 = Mild, 4 = Moderate, 5 = Moderately severe, 6 = Severe, 7 = Extremely severe SOMATIC CONCERN - Preoccupation with physical health, fear of physical illness, hypochondriasis.
ANXIETY - Worry, fear, over-concern for present or future, uneasiness EMOTIONAL WITHDRAWAL - Lack of spontaneous interaction, isolation deficiency in relating to others.
CONCEPTUAL DISORGANIZATION - Thought processes confused, disconnected, disorganized, disrupted.
MOTOR HYPERACTIVITY - Increase in energy level evidenced in more frequent movement and/or rapid speech. Do not rate if restlessness is due to akathisia.
MANNERISMS AND POSTURING - Peculiar, bizarre, unnatural motor behavior (not including tic).
GRANDIOSITY - Exaggerated self-opinion, arrogance, conviction of unusual power or abilities.
DEPRESSIVE MOOD - Sorrow, sadness, despondency, pessimism.
HOSTILITY - Animosity, contempt, belligerence, disdain for others.
SUSPICIOUSNESS - Mistrust, belief others harbor malicious or discriminatory intent.
HALLUCINATORY BEHAVIOR - Perceptions without normal external stimulus correspondence.
MOTOR RETARDATION - Slowed, weakened movements or speech, reduced body tone.
UNCOOPERATIVENESS - Resistance, guardedness, rejection of authority.
UNUSUAL THOUGHT CONTENT - Unusual, odd, strange, bizarre thought content.
BLUNTED AFFECT - Reduced emotional tone, reduction in formal intensity of feelings, flatness.
EXCITEMENT - Heightened emotional tone, agitation, increased reactivity.
DISORIENTATION - Confusion or lack of proper association for person, place or time.
ELEVATED MOOD - A pervasive, sustained and exaggerated feeling of well-being, cheerfulness, or euphoria implying a pathological mood. Optimism that is out of proportion to the circumstances.
SUICIDALITY - Expressed desire, intent, or actions to harm or kill self.
BIZARRE BEHAVIOR - Reports of behaviors which are odd, unusual, or psychotically criminal. Not limited to interview period. Include inappropriate sexual behavior and inappropriate affect.
SELF-NEGLECT - Hygiene, appearance, or eating behavior below usual expectations, below socially acceptable standards or life threatening.
DISTRACTIBILITY - Degree to which observed sequences of speech and actions are interrupted by stimuli unrelated to the interview. Distractibility is rated when the individual shows a change in the focus of attention as characterized by a pause in speech or a marked shift in gaze.
Individual's attention may be drawn to noise in adjoining room, books on a shelf,

Source: https://www.jpshealthnet.org/uploadedFiles/For_Medical_Professionals/Behavioral_Health/Research_Library/Depression/Depressive%20Disorders%20%20final.pdf

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