Depression

 

Onset (min)

Initial dose (mg)

Considerations

Benzodiazepines

Diazepam

30

5–10 IV

Avoid IM because of unpredictable absorption. Useful in the setting of alcohol withdrawal

Lorazepam

2–5 IV, 15–30 IM

1–2 IM/IV


Midazolam

120 IV, 240–300 IM

2.5–5 IM/IV

Higher risk of respiratory depression compared with lorazepam and diazepam

Antipsychotics

Aripiprazole

60

9.75 IM

Relatively safe side effect profile

Haloperidol

1–2 IV, 30–60 IM

5 IM/IV

Risk for extrapyramidal symptoms. Higher risk of QT prolongation, particularly if given IV. IV haloperidol is an off-label route and requires careful monitoring for cardiac arrhythmias if used

Olanzapine

15–45

10 IM

Use with caution when given with benzodiazepines because of increased risk of cardiopulmonary depression

Ziprasidone

30–45

20 IM

Low risk of QT prolongation



Those patients who are stratified as low or moderate risk may not require admission for psychiatric treatment, but consultation with a psychiatrist is prudent especially for moderate-risk patients. Factors arguing for safe discharge of depressed patients include:



  • Close follow-up with psychiatric consultant


  • Good social support



    • Including someone willing to stay with the patient


  • The absence of high-risk factors mentioned in the above risk factors and history sections




27.8 Other Treatment Modalities


Lifestyle changes, psychotherapy, and pharmacotherapy are all potentially effective treatment options for patients with a major depressive episode. Performance of psychotherapy is not appropriate for providers in the emergency setting because of the limited amount of time available. Patients who desire this treatment should be referred to providers who can provide these services. While emergency providers will not perform psychotherapy, it is important for them to know this is an effective option, particularly for patients with less severe depressive symptoms.


27.8.1 Lifestyle Changes


The following lifestyle changes have been shown to be efficacious in the treatment of depression:



  • Exercise*


  • Relaxation therapy*


  • Change in diet away from calorie-rich and nutrition-poor foods


  • Improved sleep hygiene



    • Including CPAP treatment for individuals with obstructive sleep apnea


  • Decreased alcohol intake

* denotes lifestyle changes that have the best evidence of efficacy [11].


27.8.2 Pharmacotherapy


There is debate about whether patients with major depression should have pharmacologic therapy initiated in the emergency department. While over 60 % of prescriptions written for antidepressants are written by nonpsychiatrists [11], many emergency providers feel initiation of pharmacotherapy in the ED should only be carried out under the direction of a psychiatrist because of the significant risk of side effects, the long period of time before drugs become effective, and the lack of adequate follow-up.

However, there are some emergency providers who do not have access to an on-call psychiatric specialist and may want to initiate therapy in the emergency setting. When unsure about the need for initiation of pharmacotherapy, there are several decision aids which can be useful. One such aid is the PHQ-9 questionnaire which uses nine questions to come up with a score from 0 to 27 and gives the recommendation to initiate pharmacotherapy for any patient with a score equal to or greater than 15 [12].

When the decision is made to treat the patient, a second-generation antidepressant should be the first-line treatment. First-generation antidepressants (tricyclic antidepressants, monoamine oxidase inhibitors) and second-generation antidepressants (selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, and atypical antidepressants) have been shown to be equally effective, but the side effect profile and overall safety relating to possible overdose make second-generation antidepressants a better option in most cases. Emergency providers should be familiar with these medications and their side effects because depressed patients may ingest these drugs during suicide attempts.
















Classes of antidepressants

Class

Mechanism of action

Important side effects

Tricyclic antidepressants (TCAs) – amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, selegiline, trimipramine

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Nov 20, 2017 | Posted by in Uncategorized | Comments Off on Depression

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