DEPRESSION/ANXIETY MANAGEMENT IN PRIMARY CARE

[Baidooba]

Hi guys,

So I work at an urgent care and usually when pt comes with depression or anxiety, we send them to primary care or ER. For those of you who work in primary care, how do you manage depression and anxiety.

[marktheshark89]

Generalized anxiety typically ssri or snri with hydroxyzine for prn to start then titrate meds based on response. Typically try to avoid benzos like the plague. If several ssris or snris arent effective then consider atypical antidepressants or antipsychotics (off label). Unipolar depression typically ssri or snri, can add wellbutrin if partial response or first line for some patients based on side effect profile etc, can add atypical antipsychotics (as an adjunct) or switch to atypical antidepressants if non responders to regular snri or ssris. Encourage therapist for most psychiatric diagnoses. Typically if the above is ineffective I will refer to psychiatry, but its pretty rare in my practice to have to do that. True anxiety or depression rarely if ever need ER care unless catatonic, suicidal, homicidal, etc from my experience. 

[mgriffiths]

marktheshark pretty much covered it.  I also avoid benzos like the plague and every patient that I inherit or comes to me as a new patient on benzos I tell them very clearly that we are going to be weaning down their 3-4x/day Xanax.  Yes benzos work well for panic attacks, but if you are needing 3-4 a day then that isn't panic attacks that's just regular old generalized anxiety.  Interestingly I've only had 1 patient so far give me push back on decreasing their med.  He hasn't been back in 3 months so I assume he found someone else to serve as his drug lord - good.

[sas5814]

Benzos are like a government entitlement program...once started they never go away.

[rev ronin]

1 hour ago, sas5814 said:

Benzos are like a government entitlement program...once started they never go away.

Not always.  For people with panic attacks, I will often give "Lorazepam 0.5 mg #6, up to bid prn anxiety attacks use sparingly", and inform the patient that I will refill those ONLY face-to-face, ONLY when they come back to me with a diary describing when, how, and why they used each pill.  Right up front I make it clear that Benzos are addictive and not for ongoing use.

I find that's the right balance between giving them out like candy (ick) and avoiding them entirely (toolbox that much emptier).  I tell them that HAVING the benzos available should decrease their overall anxiety, and I've found very good buy-in and compliance.  This is, BTW, especially from when I'm starting an SSRI, which I tell the patient takes a while to have an effect and can even mildly increase anxiety in the short term.

I'm also a big fan of referring the patient for behavioral health counseling when I start an antidepressant.  Not all will do it, but the patients willing to take a multifactorial approach to depression seem to do best.

[2wheels]

+1 for behavioral health counseling. That and diet changes/cardiovascular exercise. I try to avoid meds, depending on severity. I'd say the majority of the patients coming in for depression/anxiety can improve immensely with someone to talk to and consistent movement, especially if they're otherwise sedentary. 

[sas5814]

Zactly Rev. When I started at the Community Health Center I inherited a pile of people on 2mg of Xanax 3-4 x daily.  It was insane. It took me a long time to shift everyone away from that back to a proper tx model and many just wouldn't come back because "I've been on this for years and it works." I also got a lot of calls about patients selling their drugs too.

2wheels you are correct too but the resistance to getting folks to take care of themselves has been huge. We tend to be a "give me a pill because it is easier" society.

I minimize benzos much as you have described because they do have a proper place and panic attacks are pretty horrible. I get very frustrated with providers who are too lazy to have "the talk" and just keep giving people something that isn't good for them just because it is easy.

[Reality Check 2]

The practice I am leaving is a benzo factory. Used for everything from fibromyalgia to anxiety to "muscle spasms" and as a sleep aid.

It is ridiculous and unsafe. 

My historical training and use of benzos was 30 pills IN A YEAR and then the patient was expected to bring the bottle back and show me how many left. 

Only use for getting on airplane, getting through a funeral, a patient had to testify against her boss in a federal case and couldn't function well for 2 weeks or so. There ARE legit reasons for these meds in sparing use and close monitoring. Panic attacks are quite real and using benzos for that should ONLY be in conjunction with behavior mod therapy - in my opinion. 

Unfortunately this work environment promotes is as "quality of life" rather than RESPONSIBILITY FOR LIFE. Patients want a quick fix with no real work involved and often to not HAVE to deal with things - just fog them over and move on.

Patients also tell me that they don't want to "take a pill everyday" - meaning an SSRI and they somehow perceive a benzo as only prn and "safer" when in reality a horrible way to go.

I will face many challenges with this at the VA and have a lot more to learn about PTSD but don't plan on using benzos as a quick fix and way to "satisfy" patients. 

Over 85% of all psychoactive drugs in the US are prescribed by primary care. We still have a shortage of psychiatrists and counselors. 

As always in our profession - education, education, education, advocacy - do right by the patient.

[BruceBanner]

For routine, mild-moderate depression, I'll trial them on an SSRI.  For pervasive anxiety or severe depression, I send them to mental health within our organization. I am not a counselor nor a drug dealer. 

I used to give limited PRN Xanax rx's, and I inherited a bunch of 3-4x daily benzo patients at my old practice. They arent quite as difficult to deal with as opioid dependent patients, but you dont make any friends being the one to wean them off.

We even had a couple dozen people on 2-4mg of Xanax QHS and Adderall 30mg BID. Inexcusable.

[sk732]

We have an unwritten policy in our ER that we don't start people on anti-depressant meds unless we can guarantee follow up.  If a person is truly suicidally depressed, we'll form them and the head shrinkers can do their thing...if they need to be in a crisis unit for a few days, our mental health liaison RN can arrange that - and they get a proper psych evaluation with that.  There is a huge problem of not enough primary care psychiatrists here - they're rarer than hens' teeth.  The ones around will usually answer the question you ask them, then bounce the dude/ette back to the primary care provider for med management and treatment...if there is a primary care provider of course.  It's a bit of  a judgement call to start someone on something if you can't be sure of follow up - you never want to be the last person of record that gave someone enough energy to wack themselves...and I have been that person (as I'm sure many others here have been too).

Anxiety issues - they might get a couple lorazepams to tide them over, but what many really need is some CBT, brain and mind retraining.  Anxiety is kind of a normal thing - it's what keeps people alive; unfortunately, we live in a day and age where dyscopia is fast becoming something of a norm with a DSM-V(TR) Dx code, and people get bent out of shape when we tell them that dealing with the issues makes them go away or at least manageable, not medicating them.  Doesn't help when drug manufacturers turn things like being a bit shy into something that's pathological.  Exercise is important too - amazed at the 4 headed alien looks I get when I Rx exercise for folks for mental health management...I actually go so far as to put it on an Rx sometimes, so they have that "Doctor's order" as it were.  Days I don't exercise and choose to sleep in before a 12 hour shift can make me quite scary to be around sometimes...

When in family med, I inherited a practice of largely older people, all to a tee on temazepam, and some also with daily lorazepam and or clonazepam and or all three..."My wife/husband died so I couldn't sleep"  "How long ago was this?"  "About 7 years ago now..."  Seriously???!!!  Before I left, some new folks showed up, each on double pams daily...I told them I'd renew for a month and start the wean off.  As they'd both been on them for at least 5 years (my guess longer), I never saw them again...they were using lorazepam as a sleeping pill nightly, as well as something else...

Everything has its place...problem is, humans are generally lazy and perceive that they don't have time for things that they do have time for and don't want to look into that deep, dark vault that is our mind - it's easier to throw something down your neck to "fix" it.

 

SK

 

 

[Hckyplyr]

I'm seeing a lot of "start an SSRI", just wondering how everyone is deciding which SSRI to choose from?

[marktheshark89]

For me its mostly based on the slight differences between the drugs and the symptoms the patients present with. I rarely start with paxil because it is the hardest of the bunch to wean off of. Similarly since prozac has a long half life and washout period if discontinued its usually not my first choice (unless i have a patient with poor compliance who often forgets to take their med).  Zoloft and prozac tend to be more activating while paxil and celexa more sedating with lexapro often more neutral (per several psychiaty colleagues), so I often think about those properties. Zoloft tends to have more diarrhea than others so in ibs-d patients I'll often avoid that one, just as an example. I also tend to ask about if any siblings or parents have used ssris before and which they have had success with. Its anecdotal but i tend to have better luck using the one that has been successful for other family members.

[True Anomaly]

Why are you sending depression/anxiety to the ER?  Unless they are suicidal/homicidal/actively psychotic, there is nothing I will do in the ER that you can't do at an urgent care- and they get charged an extra visit

[d2305]

Zoloft is the best ssri, but they will feel anxious when they stop taking it. I think Celexa is a placebo.

[marktheshark89]

38 minutes ago, d2305 said:

Zoloft is the best ssri, but they will feel anxious when they stop taking it. I think Celexa is a placebo.

What do you mean by "the best"? 

[rev ronin]

7 hours ago, marktheshark89 said:

What do you mean by "the best"? 

Sertraline has a lot of different indications, reasonable cost, reasonable side effect profile.  I usually start folks off with it first if there's no compelling reason to choose another SSRI... but I wouldn't make a blanket statement that it's always the best in every circumstance.

[LT_Oneal_PAC]

On 7/28/2017 at 11:42 PM, Hckyplyr said:

I'm seeing a lot of "start an SSRI", just wondering how everyone is deciding which SSRI to choose from?

I have a pretty nuanced approach. When first starting out I would ask others what they though and almost everyone had a different answer. Pretty practice dependent. 

Personally use mostly Zoloft which I find is good for people presenting with mixed anxiety and depression. I have a high female patient population and it's better studied in pregnancy and breast feeding. Higher anxiety use lexapro or Paxil. More depression, overweight, scared of decreased libido, ADD, use Wellbutrin. Prozac for the fickle people who think will hate whatever I put them on because of its long half life it weans itself. Persistent anxiety on an the original SSRI may add buspar as an adjunct. Too much fatigue may adjunct with Wellbutrin. Don't use much celexa unless failed others.

I hate Effexor. I've had to write out too many complicated 3 month long tapers because of the withdrawal effects.

[myironlung]

On 7/27/2017 at 6:24 PM, Baidooba said:

Hi guys,

So I work at an urgent care and usually when pt comes with depression or anxiety, we send them to primary care or ER. For those of you who work in primary care, how do you manage depression and anxiety.

I never start any psych meds. I just refer to psych. People need mental health counseling first and I'm not a psychologist.

[Hckyplyr]

On 7/29/2017 at 10:45 AM, marktheshark89 said:

For me its mostly based on the slight differences between the drugs and the symptoms the patients present with. I rarely start with paxil because it is the hardest of the bunch to wean off of. Similarly since prozac has a long half life and washout period if discontinued its usually not my first choice (unless i have a patient with poor compliance who often forgets to take their med).  Zoloft and prozac tend to be more activating while paxil and celexa more sedating with lexapro often more neutral (per several psychiaty colleagues), so I often think about those properties. Zoloft tends to have more diarrhea than others so in ibs-d patients I'll often avoid that one, just as an example. I also tend to ask about if any siblings or parents have used ssris before and which they have had success with. Its anecdotal but i tend to have better luck using the one that has been successful for other family members.

This is a fantastic post. I just finished a psych rotation with a well renowned psychiatrist, and your comments essentially mirrored all they things he was teaching. I feel like many providers have no idea how to tailor each SSRI to the patient, and just randomly pick one. 

1 hour ago, LT_Oneal_PAC said:

I have a pretty nuanced approach. When first starting out I would ask others what they though and almost everyone had a different answer. Pretty practice dependent. 

Personally use mostly Zoloft which I find is good for people presenting with mixed anxiety and depression. I have a high female patient population and it's better studied in pregnancy and breast feeding. Higher anxiety use lexapro or Paxil. More depression, overweight, scared of decreased libido, ADD, use Wellbutrin. Prozac for the fickle people who think will hate whatever I put them on because of its long half life it weans itself. Persistent anxiety on an the original SSRI may add buspar as an adjunct. Too much fatigue may adjunct with Wellbutrin. Don't use much celexa unless failed others.

I hate Effexor. I've had to write out too many complicated 3 month long tapers because of the withdrawal effects.

The guy I was with was pretty adamant that Wellbutrin does not work for anxiety, its great for atypical depression. But as you eluded to, it will work fantastic for patients who need a boost in energy, focus/concentration, no libido problems and weight neutral/loss. Your adjunct treatments are great too. I'd add that Ability works really well for depression at low doses <10mg, as it acts as a dopamine agonist. Anything over 10mg and it works more like an antagonist, hence why its useful for bipolar and schizophrenia at those doses. 

[d2305]

Zoloft the best?  I was going to post a study, but it's expired.

[Reality Check 2]

My approach was different in ER vs FP.

ER - no follow up guaranteed. If you start meds - SOMEONE has to be there to watch for mania, suicidality, side effects. It is not - here's your pill.

From an FP approach these are my experiences over years and years - nothing clinically studied but my findings from watching batches of patients.

Depression - depends on age and symptoms. I went to a fantastic suicide lecture in the state of Washington - elderly do better on Prozac, younger on Celexa and Lexapro.

I do not like Paxil or Zoloft except in specific situations. I think zoloft makes people too flat, too fat and the withdrawal is extensive. Paxil - miss one dose and have ants crawling all over. Paxil has very specific benefit in advanced OCD and some other situations. Zoloft has pretty excessive sexual side effects.

Celexa is good but higher dose needed a lot and that gets uncomfortable. Lexapro is cleaner, subtle, non sedating in my experience, calming and no withdrawals. Lexapro is my main drug of choice in mid age range for both anxiety and depression. I use more Prozac over 60. NEVER seen Prozac do squat for true anxiety. 

Wellbutrin good in depression. I see it make anxious people more anxious and downright agitated and angry. It is good with ADD and safer if ANY suspicion of bipolar or schizophrenia. Won't push into mania like SSRIs. Wellbutrin mixes well with SSRIs. Watch for insomnia - always taken in the morning. Watch for a-fib - don't use it with that. Seizure d/o = no no. Watch hypertension and tachycardia. 

SNRIs - meh, ok, for some. Effexor is a pain to wean and can be dose picky - patients may need a dose that doesn't exist - everything doubles on that one. Short release Effexor is AWFUL. Cymbalta - ok - used it in chronic pain and diabetic neuropathy - it helps - these aren't terribly happy people and do not expect them to be Mary Poppins or PollyAnna no matter what you give them. 

ALWAYS be careful with Tramadol - same 5HTP receptor - serotonin syndrome. If they take 2 tramadol a day and never more - I leave their SSRI alone. If tramadol does more for them than the SSRI, I cut the SSRI down. Too many times see SSRI, benzo, tramadol, ambien AND some sort of stimulant - these people are a foggy freaking mess.

Seroquel is GREAT for agitated depression - the ones who will punch walls and break chairs. There is a huge difference between sleep dose and psychotic dose. Ramp it up FAST to treat bipolar or schizophrenia - get to 200 mg bid within 4-5 days to overcome overwhelming somnolence. It takes away the GI sense of fullness and people overeat, gain weight and become insulin resistant - discuss, explain, reiterate, discuss again. Set timers at the table. One serving of foods - 15 minutes to eat. No refills for at least 20 minutes and only after consideration. Seroquel at 25-50 qhs will put folks to sleep - mixes ok with SSRI.

Zyprexa - yeah, it works - special population. Dementia patient, agitated, hits people, up all night - wanders - 2.5 mg at dinner - night night. Younger folks - see your psychiatrist.

Geodon - YACK - don't bother. Hate it. Injected in ER is awful. Stick with Haldol, Ativan IM STAT to calm the psycho swinging the chair. 

Abilify - ok, used it some - hard to titrate to level vs sleepy vs goofy. 

Haven't worked with Latuda and the other new interestingly named atypicals. Too many patients on state insurance and it won't cover anything but the generics.

Risperdal - YUCK. Gynecomastia, flat affect, hypersomnolence. LOTS of court ordered IM long acting for refractory patients requiring 24/7 monitoring and guidance. Special population.

Benzos - bad news. NEVER intended to be taken daily, regularly, scheduled, etc. This stuff needs to calm down. Dealing with daily life should not involve a hazy cloud of "I don't give a crap". They have their role - it is limited and has to be monitored. STOP MIXING WITH NARCOTICS AND ETOH AND WEED AND WHATEVER.

Buspar not as fun as benzos - hard to comply with TID dosing, no buzz but in retrospect, people do see that they coped better.

Bottom line - meds are only ONE prong of the treatment - counseling, realistic expectations, behavior modification - all play a major role.

Just my crusty old 2 cents................

 

[Reality Check 2]

https://www.psychologytoday.com/blog/two-takes-depression/201407/genetic-testing-better-depression-treatment

And do not forget the genetic testing - I have not used this yet but have seen many reports.

Still doing more research on this and how to use, how to order, how much does it cost....................

[DizzyJ]

24 minutes ago, Reality Check 2 said:

https://www.psychologytoday.com/blog/two-takes-depression/201407/genetic-testing-better-depression-treatment

And do not forget the genetic testing - I have not used this yet but have seen many reports.

Still doing more research on this and how to use, how to order, how much does it cost....................

When I worked outpatient psych we would order these tests.......bottom line is they are pretty much useless.  You get a report back showing what medication should be metabolized efficiently, which should be avoided or used at lower doses, and which may need higher doses then usual.  Okay, but that doesn't mean the medication will actually work.  After doing these on a handful of patients and then seeing they have already tried and failed all the meds that came back flagged as "green" meaning they are the best choices.  Waste of money in my opinion. 

[LT_Oneal_PAC]

19 hours ago, Hckyplyr said:

This is a fantastic post. I just finished a psych rotation with a well renowned psychiatrist, and your comments essentially mirrored all they things he was teaching. I feel like many providers have no idea how to tailor each SSRI to the patient, and just randomly pick one. 

The guy I was with was pretty adamant that Wellbutrin does not work for anxiety, its great for atypical depression. But as you eluded to, it will work fantastic for patients who need a boost in energy, focus/concentration, no libido problems and weight neutral/loss. Your adjunct treatments are great too. I'd add that Ability works really well for depression at low doses <10mg, as it acts as a dopamine agonist. Anything over 10mg and it works more like an antagonist, hence why its useful for bipolar and schizophrenia at those doses. 

I agree. Never said Wellbutrin with anxiety.  I've seen it tried by others for obese patients wanting weight loss and it always exacerbates it. I said depression. Though one should not confused irritability with anxiety, which I've often seen mistaken.

 

good tip on the abilify. Will have to look into that. Don't use it much since I don't have time in 20 min appointments to handle most of my bipolar patients.

[Joelseff]

Sertraline has a lot of different indications, reasonable cost, reasonable side effect profile.  I usually start folks off with it first if there's no compelling reason to choose another SSRI... but I wouldn't make a blanket statement that it's always the best in every circumstance.

I would day it's a good choice for MDD with general anxiety sxs but if you are targeting certain symptoms you may want to pick another drug with better control of the target symptom.

 

OH and make sure to check Na levels.

 

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