Copyright Mental Health Connections, Inc. 1996-9.
Start
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Diagnose organic medical causes,
drug side effects and drug abuse
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__________________Diagnosis?________________
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Dysthymic dis. & Major depression Bipolar
Depression NOS psychotic|nonpsychotic depression
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| More..(#1) | More..(#3)
Mood reactive? Melancholic?
Yes No Yes No
| |__Severely depressed?_| |
| Yes No |
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| More..(#2) | |
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|______Adequate trial _|____________|
____of SSRI/bupropion SR?_____
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No Yes one Yes more than one
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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 |
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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
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If severely ill, have you considered ECT?
No |
| Milder illness, tried ECT,
Try ECT (05) or ECT unacceptable?
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Adequate trial of tricyclic + antipsychotic?
Yes No
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| 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
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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
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Is there significant ischemia?
Yes No
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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)
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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
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Urgent indication for ECT present?
No Yes
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| ECT recommended. If refused or unsuccessful,
| go on to the next question. (46)
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Is the patient psychotic?
No Yes
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| Include antipsychotic in regimen below.
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_____________________Bipolar type?_______________________
Bipolar II Bipolar I Mixed or rapid cycling
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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
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Add SSRI or Trial of venlafaxine?
bupropion (22[P]) | |
No Yes
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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
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Melancholic type?
non-melancholic melancholic
(mood reactive) (mood non-reactive)
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| Comment on melancholia
Personality disorder? |
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Comment <-- Avoidant |
| Comment <--Borderline |
| | Comment <--Narcissistic |
| | | Comment <--Dependent |
| | | | Comment <--None of above |
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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)
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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)
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Candidate for monotherapy with an antidepressant?
Yes No
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Tried SSRI or bupropion? Treat the same as bipolar I
No Yes More..(#3)
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Try SSRI/bupropion Another trial of SSRI/bupropion?
(37[P]) No Yes
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Do another Tried venlafaxine?
SSRI/bupropion | |
trial (38[P]) No Yes
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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
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Predisposing factors considered and addressed?
Yes No
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Current medications? Address factors where
No mood One or more possible (41[P])
stabilizer mood stabilizers
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Try VPA Tried adding second mood stabilizer?
(42[P]) | |
No Yes
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Try adding second Bipolar subtype?
mood stabilizer (43[P]) | |
Bipolar I Bipolar II
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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])
For convenience and paper conservation,
the entire flowchart can be placed on
two sides of a page and then photocopied
for routine use.