Caution: Do not use this flowchart to find treatment recommendations
for patients. It is intended only as an overview of the topics covered.
Answer the questions and read the associated texts which contain the
evidence-supported discussion, reasoning, and analysis of alternatives.
Start
|
Diagnose organic medical causes,
drug side effects and drug abuse
|
|
__________________Diagnosis?________________
| | |
Dysthymic dis. & Major depression Bipolar
Depression NOS psychotic|nonpsychotic depression
| | | |
| More..(#1) | More..(#3)
Mood reactive? Melancholic?
Yes No Yes No
| |__Severely depressed?_| |
| Yes No |
| | | |
| More..(#2) | |
| | |
|______Adequate trial _|____________|
____of SSRI/bupropion SR?_____
| | |
No Yes one Yes more than one
| | |
Give Urgency for relief? |
SSRI/ Not high High |
Bup SR | | |
(01) Try a Adequate trial of a
second tricyclic, venlafax, mirtaz, or (TCA + SSRI)?
SSRI/ No Yes
Bup SR | |
(02) Add TCA or replace Is this an
with tricyclic, Atypical depression?
venlafaxine Yes No
or mirtazapine | |
(03) Adequate trial of MAOI? |
(Bupropion may precede.) |
No Yes |
| | |
Try MAOI (bupropion may | |
precede) (04) | |
This is a
PHARMACOTHERAPY RESISTANT DEPRESSION
More..(#4)
[Go to source of this branch]
#1. Continuing from:
Major depression, psychotic
|
If severely ill, have you considered ECT?
No |
| Milder illness, tried ECT,
Try ECT (05) or ECT unacceptable?
|
Adequate trial of tricyclic + antipsychotic?
Yes No
| |
| Is trial of this combination acceptable?
| Yes TCA unac- Prefer to avoid
| | ceptable antipsychotic
| Try TCA + | |
| antipsychotic (06) | |
| Adequate trial of |
Adequate trial SSRI + antipsychotic? |
with lithium added? No Yes |
No Yes | | |
| | Try SSRI + Trial of |
Add lithium; Trial of antipsychotic; added Li+? |
Reconsider methyl- (? AP alone) No Yes |
ECT (07) phenidate? (25) | | |
No Yes Reconsider ECT ECT |
| | or add Li+ (10) (11) |
Add methyl- ECT; Trial of
phenidate (? clozapine) antidepressant alone?
(08) (09) Yes No
| |
Add Li+ Try 3° amine
(12) TCA; Certain SSRI's:
worthy of more study
(13)
[Go to source of this branch]
#2. Continuing from:
Severely depressed: Yes
|
Is there significant ischemia?
Yes No
| |
Choose Significant dementia?
Pharmaco- ECT Yes No
therapy (26) | |
| | Trial of tricyclic?
Trial of SSRI or bupropion? Yes No
No Yes | |
| | | Try tricyclic,
Try SSRI or Reconsider ECT? | venlafax/mirtaz
bupropion accepts rejects | (15)
(14) | | |
ECT (27) | |
| Trial of SSRI added?
Trial of venlafax/mirtaz, Yes No
lithium augmentation etc.? | |
No Yes | Try adding SSRI (16)
| | |
Try venlafax/mirtaz This is a PHARMACOTHERAPY RESISTANT
or lithium augmen- DEPRESSION
tation etc. (17) More..(#4)
[Go to source of this branch]
#3. Continuing from:
Bipolar depression
|
Urgent indication for ECT present?
No Yes
| |
| ECT recommended. If refused or unsuccessful,
| go on to the next question. (46)
| |
Is the patient psychotic?
No Yes
| |
| Include antipsychotic in regimen below.
| |
_____________________Bipolar type?_______________________
Bipolar II Bipolar I Mixed or rapid cycling
| | |
More..(#5) | More..(#6)
__________Current medications?________________________
Lithium VPA, CBZ, etc. No mood stabilizers
(+/- others) | |
| Optimize |
Li level >0.8? levels Depression severity?
| | to prevent Moderate/Severe Mild
No Yes (or cycling | |
| intolerable) | Trial of SSRI Try Li
Raise | | or bupropion + or...
level Tried adding SSRI or lithium or VPA (20[P])
to bupropion? (19[P])
0.8-1.2 No Yes
(18[P]) | |
Add SSRI Second trial of
or bupropion SSRI/bupropion?
(21[P]) No Yes
| |
Add SSRI or Trial of venlafaxine?
bupropion (22[P]) | |
No Yes
| |
Try venlafaxine, Consider comorbid conditions,
or others (23[P]) consider MAOI or ECT
Refractory Bipolar Depression (24[P])
[Go to source of this branch]
#4. Continuing from:
This is a PHARMACOTHERAPY RESISTANT DEPRESSION
|
Melancholic type?
non-melancholic melancholic
(mood reactive) (mood non-reactive)
| |
| Comment on melancholia
Personality disorder? |
| | | | | |
Comment <-- Avoidant |
| Comment <--Borderline |
| | Comment <--Narcissistic |
| | | Comment <--Dependent |
| | | | Comment <--None of above |
| | | | | |
Comorbid condition? <------------------|
| | | | | | |
Panic disorder
| OCD
| | ADHD
| | | PTSD
| | | | Chronic pain
| | | | | Moderate anergic depression with medical illness
| | | | | | None (or, you followed up on the comorbidities)
| | | | | | |
| | | | | | Try additional single treatments: e.g.
| | | | | A SSRI's (maybe high dose), TCA's,
| | | | | n clomipramine (if no ischemia), MAOI's
| | | | | e Consider ECT.Try enhancement strategies:
| | | | | r lithium, bupropion, thyroid, stimulants,
| | | | P g pindolol, buspirone, MAOI with lithium
| | | | A i or stimulants. (28)
| | | P I c
P O A T N Try stimulants (29)
A C D S |
N D H D Try carbamazepine, amitriptyline, tramadol
I | D | clomipramine, venlafaxine (30)
C | | Consider trazodone for sleep. Substance abuse?
| | | Yes--> Add valproate or carbamazepine; ?gabapentin (32)
| | | No---> Benzodiazepines; then valproate, carbamazepine,
| | | antipsychotics for psychosis NOS, MAOI's (31)
| | |
P O Substance abuse?
A C Yes--> Consider bupropion; venlafaxine (if not cocaine user) (33)
N D No--> Consider stimulants, bupropion, venlafaxine (34)
I |
C Consider: high dose SSRI then clomipramine +/- SSRI;
| then other enhancers (Li+, buspirone, MAOI): if psychotic
| features or tics, consider antipsychotics (35)
|
Try: Benzodiazepines, Low dose SSRI, Valproate, MAOI (36)
[Go to source of this branch]
#5. Continuing from:
Bipolar II (not rapid-cycling)
|
Candidate for monotherapy with an antidepressant?
Yes No
| |
Tried SSRI or bupropion? Treat the same as bipolar I
No Yes More..(#3)
| |
Try SSRI/bupropion Another trial of SSRI/bupropion?
(37[P]) No Yes
| |
Do another Tried venlafaxine?
SSRI/bupropion | |
trial (38[P]) No Yes
| |
Try venlafaxine comorbid conditions
or others (39[P]) Consider an MAOI or ECT
Refractory Bipolar Depression (40[P])
[Go to source of this branch]
#6. Continuing from:
Bipolar I or II: Mixed or rapid cycling
|
Predisposing factors considered and addressed?
Yes No
| |
Current medications? Address factors where
No mood One or more possible (41[P])
stabilizer mood stabilizers
| |
Try VPA Tried adding second mood stabilizer?
(42[P]) | |
No Yes
| |
Try adding second Bipolar subtype?
mood stabilizer (43[P]) | |
Bipolar I Bipolar II
| |
Consider third mood stabilizer. Consider third mood stabilizer,
If antidepressant chosen, start ECT, or newer antipsychotics. If
bupropion or SSRI. Use low dose, antidepressant chosen, start
go slow strategy (44[P]) bupropion or SSRI. Use low dose,
go slow strategy (45[P])