Depressive Disorders

(F30) Manic episode (F32) Depressive episode

(F30.0) (F32.0) Mild depressive episode

(F30.1) without psychotic symptoms (F32.1) Moderate depressive episode

(F30.2) Mania with psychotic symptoms (F32.2) Severe depressive episode without psychotic symptoms (F30.8) Other manic episodes (F32.3) Severe depressive episode with (F30.9) Manic episode, unspecified psychotic symptoms (F31) Bipolar affective disorder (F32.8) Other depressive episodes (F31.0) Bipolar affective disorder, current • Atypical episode hypomanic • Single episodes of "masked" (F31.1) Bipolar affective disorder, current depression NOS episode manic without psychotic symptoms (F32.9) Depressive episode, unspecified

(F31.2) Bipolar affective disorder, current (F33) Recurrent depressive disorder episode manic with psychotic symptoms (F33.0) Recurrent depressive disorder, current (F31.3) Bipolar affective disorder, current episode mild episode mild or moderate depression (F33.1) Recurrent depressive disorder, current (F31.4) Bipolar affective disorder, current episode moderate episode severe depression without psychotic (F33.2) Recurrent depressive disorder, current symptoms episode severe without psychotic symptoms

(F31.5) Bipolar affective disorder, current (F33.3) Recurrent depressive disorder, current episode severe depression with psychotic episode severe with psychotic symptoms symptoms (F33.4) Recurrent depressive disorder, currently (F31.6) Bipolar affective disorder, current in remission episode mixed (F33.8) Other recurrent depressive disorders (F31.7) Bipolar affective disorder, currently in remission (F33.9) Recurrent depressive disorder, unspecified (F31.8) Other bipolar affective disorders

• Bipolar II disorder • Recurrent manic episodes NOS (F31.9) Bipolar affective disorder, unspecified

Other Mood Disorders Adjustment Disorders (F38) Other mood (affective) disorders (F43.20) , Unspecified (F38.0) Other single mood (affective) (F43.22) Adjustment disorder, With disorders (F43.21) Adjustment disorder, With depressed • Mixed affective episode mood (F38.1) Other recurrent mood (affective) (F43.24) Adjustment disorder, With disturbance disorders of conduct

• Recurrent brief depressive (F43.25) Adjustment disorder, With mixed episodes anxiety and depressed mood (F38.8) Other specified mood (affective) (F43.25) Adjustment disorder, With mixed disorders disturbance of emotions and conduct (F39) Unspecified mood (affective) disorder

Antidepressants

Drug Dosage FDA Benefits Risk/side effects PEARLS Special Considerations indication SSRIs 10-80mg/day Depression, Activating, non- Headache, Great for those with Potent 2D6 inhibitor (Prozac) (start 20mg) Bulimia, selective, Nausea, Tremor, disorder or OCD, Panic inexpensive, long ½ Sweats, Sexual long term depression disorder life, little to no Side Effects, and/or treatment resistance discontinuation Dulling of affect; depression. long ½ life with active Dose in the morning metabolite; most likely to induce Not very serotonin mania selective, also works on norepi. Get big “bang for your buck” Citalopram 10-40mg/day Depression Mildly sedating, Headache, Great for those with mild Impairs Platelet Aggregation; (Celexa) (over 40mg Well tolerated, does Nausea, sexual depression, or first episode Risk of SIADH black box not interact with side effects, depression. Extremely warning). Start most meds, easy sedating; may serotonin selective, no 20mg dosing range, not be as norepi effects. intermediate ½ life effective since it is very selective; Can dose morning or QT prolongation bedtime 10-20mg/day; Depression, Mildly sedating, Headache, Will use when need a very (Lexapro) 10mg Lexapro= Generalized Very selective, Nausea selective serotonin agent 20mg celexa Anxiety minimal side effects, but moderate-severe Disorder well tolerated, least depression. sexual side effects of SSRIs 50-200mg Day Depression, Activating, only Most GI side Caution: May cause (Zoloft) (usually start Panic, OCD, SSRI safe in effects; Sexual agitation in the first week-2 100mg/day) PMDD, cardiac disease, Side Effects, weeks of treatment PTSD, Social short ½ life Large dose especially in SSRI naïve Anxiety range, BID patients. Start low, go slow, dosing for warn patients. Only take in tolerance at the morning to start. 200mg/day; max absorption requires full stomach

Paroxetine 10-60mg/day Depression, Mildly sedating; Headache, I usually do not use as a Potent 2D6 inhibitor (Paxil) GAD, OCD, short ½ life; no Nausea, sexual first line agent because of Can potentiate bradycardia with Panic, active metabolite side effects, side effects and drug metoprolol; can decrease PMDD, anticholinergic interactions. analgesic effects with tramadol PTSD, Social side effects; Anxiety weight gain; discontinuation syndrome SNRIs XR: 37.5- Depression, Works well with Severe Start low, go slow. Warn Can take several weeks to wean (Effexor) 225mg Daily GAD, , depression, discontinuation about first week side off; (don’t Anxiety, ADD; Best 5HT to syndrome; Can effects: sweating, agitation, recommend IR) Panic NE ratio; usually raise BP; Risk jaw clenching, dizziness, will know quickly if with seizures; problems with sleep. effective; weight Many people neutral; short ½ life; cannot tolerate; About 10% of my patients renal clearance some QT can’t tolerate for various prolongation reasons Desvenlafaxine 50mg/day (can Depression, Better tolerated than Same as Effexor Will use when Effexor is Same as effexor (Pristiq) increase to Generalized Effexor; easy clinically effective, but side 100mg/day but Anxiety dosing; quick effects are unbearable limited benefit) Disorder efficacy; works well; weight neutral Duloxetine 30-120mg/day Depression, Calming; quick Can increase Great to use with chronic Moderate 2D6 inhibitor (Cymbalta) Generalized efficacy blood pressure; pain, fibromyalgia. Usually Avoid in Renal and Hepatic Anxiety can be overly my first line for these Dysfunction Disorder; sedating; poorly people. Fibromyalgia; tolerated in some Chronic Pain TCAs Amitriptyline 25-300mg/day Depression Sedating; very Sedating; cardiac Works very well for sleep Major substrate of 2D6; avoid (QD or BID) effective; can use to effects; or pm anxiety. Can use in with Alpha-1 antagonists or augment SSRI anticholinergic junction with SSRI Alpha-2 agonists; C/I in h/o MI effects; (monitor for serotonin orthostatic syndrome). Has serotonin, hypotension norepi and dopamine effects. Good for problems with concentration

Antidepressants

Nortriptyline 25-150mg/day Depression Sedating; very Same Great for chronic pain. Has same effective in chronic serotonin, norepi and pain/migraines; can dopamine effects use with SSRI Imipramine 25- 300mg Depressio Stimulant effects; Some may not same can work as well or tolerate; cardiac better than effects; amphetamines in anticholinergic ADHD effects; orthostatic hypotension Clomipramine 25-250 Depresion, Same as Same as same OCD amitriptyline amitriptyline Others Mirtazapine 15-45mg/day Depression Sedating, stimulates +++Weight gain Great first line drug for Rare Agranulocytosis appetite, very mod-severe effective, well depression/anxiety. Great tolerated, can use to for elderly when appetite augment SSRI stimulation needed. Buspirone 5mg-20mg TID Anxiety Well tolerated; Headache, 3A4 substrate calming; serotonin nausea effects Vortioxetine 10mg x 4 days MDD Easy dosing; well Still very new; Have not used on anyone (Brintellix) then 20mg tolerated; no sexual unknown yet. side effects mechanism of action; SIADH

Mood Stabilizers

Drug Dosage FDA Benefits Risk/side effects PEARLS Special Considerations indication Antiepileptics (AED) Divalproex Load: Bipolar Works great in Hard on the liver, My go to med for males Pregnancy Category D Valrpoic Acid 20mg/kg/day IR Disorder individuals with must monitor with bipolar d/o. Great for Do not use in pancreatitis/liver (Depakote, 500mg ER (acute anger, aggression, LFTs (monitor criminal population (anger, failure Depakote ER, Manic/Mixed) mania. ER dosing is monthly, then q aggression, impulsivity Must Taper to wean off (risk of Depakene) Adjust to VPA once daily. IR 3-6 mths). Must control). withdrawal seizures) level of 50-125 Approved for formulation is cheap. monitor drug May lead to PCOS in females (blocks bipolar mania Can be combined levels q 3-6 mths. Works well for control of voltage-gated in with or Weight gain. anxiety. Can help with Na channels; children/teens Seroquel. Nausea, PTSD. increases vomiting, tremor GABA Off label: (treat with Need higher dosing for ER concentrations) anger, propranolol) as only 80% bioavailable aggression, bipolar Helpful with migraine depression control Load: 200mg Bipolar Works great in Titrate slowly. Most often used 2nd line. Pregnancy Category D (Tegretol, BID to max of Disorder individuals with Monitor Will use when failed other Must Taper to wean off (risk of tegretol XR) 1600mg/day anger, aggression, LFTs/BMP/CBC/ mood stabilizers or in withdrawal seizures) Off label: mania. Works with EKG. conjunction with lithium or Risk of hyponatremia (Voltage gated Goal CBZ level anger, and anger . Risk of aplastic anemia, Na-channel of 6-12 aggression in It induces its own agranulocytosis blockade; PTSD/Dissociative metabolism at Some help with control of Risk of Stevens-Johnson inhibits ID disorder. first so may take anxiety and PTSD. Syndrome glutamate up to a month for 3A4 inducer release) steady state Helpful with neuropathic pain 300mg BID up Off label: No weight gain. No Same risks as Great when carbamazepine Decreases effectivness of BCP (Trileptal) to 1200mg BID Bipolar drug monitoring CBZ, but to less works, but pt will not *Use highest dose estrogen Disorder needed. extent. comply with drug level BCP (Voltage gated Do not have to testing. Risk of Hyponatremia Na-channel monitor drug Must Taper to wean off (risk of blockade; levels, but drug Some help with control of withdrawal seizures) inhibits levels can be anxiety and PTSD. glutamate tested release) Mood Stabilizers

Lamotrigine 25mg / day x 2 Bipolar Works very well in Few adverse Works well in women, Risk of Stevens-Johnsons (< (Lamictal) weeks disorder bipolar depression. effects especially women with 1%, highest risk is during initial 50mg / day x 2 Weight neutral. No (headaches, borderline PD in addition loading) (Voltage gated weeks drug monitoring. dizziness, to bipolar. More effective Must Taper to wean off (risk of Na-channel 75mg/day x 2 somnolence, than lithium for preventing withdrawal seizures) blockade; weeks Useful in treating nausea). depressive episodes. Will Oral BCP may increase inhibits 100mg / day x 2 aggression/agitation use for treatment resistant clearance glutamate weeks in TBI or major depression. release) Max: 200mg/day Also effective in treating anxiety. Will use in PTSD. Decrease by ½ when using with valproic acid

Double dose if used with carbamazepine

Topiramate 25mg BID up to Off label for Rarely use as monotherapy (Topamax) 200mg BID bipolar d/o in bipolar disorder

Mood Stabilizers

Other Lithium 300 mg bid or Bipolar Inexpensive and Weight gain, My go to drug in females Pregnancy Cat D (carbonate and tid maintenance, effective. tremor (treat with especially those with 3% of patients develop goiter Eskalith) 900 – 1200 mg mania and Vit E 400mg borderline PD and/or self 5% of patients develop maintence depression Neuroprotective BID), hair loss, harm, . hypothyroidism (unknown 1800 mg day ~ effects (activates polyuria, Use to augment Lithium is sodium bound ~ MOA) acute episode trophic actions at the nausea/diarrhea when high serum sodium lowers synapse) chronic suicidal ideation is lithium level Serum Drug Caution in renal present. Also good for low serum sodium elevates Levels: Antisuicide disease anger and irritability lithium level > 0.5mEq/L properties √ renal function AVOID DEHYDRATION ~ therapeutic tests / thyroid / SWEATING 0.8 – CBC with diff / 1.2mEq/L for lytes/ sp. gravity Risk for (as acute episode if renal disease low as 1- 1.5 mEq/L) 0.6 – do 24 h Cr Symptoms: tremors, cognitive 1.2mEq/L for clearance impairment, fatigue, N/V/D, maintenance thirst, > 1.5mEq/L is √ lithium level indigestion, weight gain, rash, toxic biweekly to start hair loss, √ every 3-6 edema of legs (may need to months… stop med) *diarrhea can be severe / Δ Use ER lytes! formulation if *risk of diabetes insipidus side effects *NOT with thiazide diuretic or problematic NSAIDS Spironolactone if diurectic is needed *NOT in patients with renal failure

Antipsychotics in mood disorders

Drug Dosage FDA Benefits Risk/side effects PEARLS Special Considerations indication Atypicals (2 nd generation)

Blocks D2 hyperactivity; reduces glutamate activity by different mechanisms; Serotonin 2A *CAUTION in folks with DM, hyper and hypglycemia antagonism which causes efficacy in bipolar mania and weight gain is problamatic , cardiac problems / stroke akathesia, EPS, tartive dyskansia Multiple mechanisms cause increased availability of serotonin, dopamine and norepinephrine which cause efficacy in bipolar depression Monitor weight, lipids and A1C

Risperidone 0.5mg – 6mg Bipolar few anticholinergics ↑ risk for movement Most “typical” of the 2D6 substrate (Risperdal) Consta – 25mg- mania/mixed side effects. Mild disorders atypicals as dose rises 75mg IM q 2 /maintenance sedation. Once a day ↑prolactin Primarily renal excretion wks or BID dosing Cheap and very effective, (care in renal disease) usually well tolerated. time to peak: 1 hr Caution in hepatic One of my first lines as it has impairment less sedation/weight gain of other inexpensive atypicals

Olanzapine 5mg – 20mg, Bipolar ↓ EPS ↑ ↑ weight gain, Improves mood in bipolar 2D6 substrate (Zyprexa) but frequently mania/ mixed Mildly sedating greatest and depression especially Rare DKA/HHNK used up to depression/ Does not raise cardiometabolic when combined with 30mg/day maintenance prolactin effects fluoxetine. Smoking will reduce levels Time to peak: 6 hrs Available in ODT, but time to onset no quicker Caution in hepatic impairment 25mg- Bipolar Virtually NO EPS / very sedating Lack of EPS makes it 3A4 substrate (fluoxetine (seroquel) 800mg/day mania/ TD. No prolactin. weight gain preferred in parkinsons and will increase levels, CBZ depression/ helps with sleep cardiometabolic bipolar/. will decrease levels) maintenance onset effects (less than Zyprexa) Good antidepressant action Primarily renal excretion XR (care in renal disease) formulation: QTC prolongation Start low and go slow in Caution in hepatic depression risk (ave 12ms): naïve patients. impairment augmentation monitor EKG and Caution in seizure care with other QTC disorder prolonging agents in mood disorders

Ziprasidone 20mg to 80mg Bipolar Low EPS NOT with electrolyte Works better at higher doses 3A4 substrate(fluoxetine (Geodon) BID mania/mixed/ Low prolactin problems than lower, so quick will increase levels, CBZ maintenance effects QTC prolongation uptitration will decrease levels) no weight gain risk (ave 20ms): lowers lipid levels monitor EKG and increased uptake with food Safer in renal disease mild sedation care with other QTC (PO formulation) prolonging agents Antidepressant and anxiolytic effects Caution in CHF

Good less expensive alternative to abilify if metabolic effects are concerning Aripriprazole 2.5mg – 5mg to Bipolar no weight gain ↑ risk for movement Works well in treating mania, 2D6 substrate (Abilify) 30mg / daily mania/mixed/ little to no disorders/ akathisia aggression, agitation 3A4 substrate (fluoxetine slowly maintenance cardiometabolic will increase levels, CBZ effects Activating, very little Slow time to steady state: ½ will decrease levels) Depression sedation life is 75 hrs! Augmentation Now generic, but still Not effective as a single VERY expensive agent when speed is needed ($20-$30 a PILL) Lurasidone 201-120mg/day Bipolar No weight gain Well tolerated Must take with small meal Caution in renal and (Latuda) Depression little to no Mild sedation (400cal) hepatic impairment cardiometabolic Nausea effects Brand only so Minimal cognitive effects little risk for EPS expensive Anxiolytic effects

For some reason I have had the best result in African American females.