Abandon | All | Hope | Ye | Who | Enter | The | Hall | Of | Bloat | ||||||||
/ MBASIC Delphi OWL C++/C# MFC WScript Visual Basic OLE ActiveX/ Visual.NET/ Hellware* | SitemapStart | 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/nefaz?__________ | | | No Yes one Yes more than one | | | Give Urgency for relief? | SSRI/ Not high High | Nefaz | | | (01) Try a Adequate trial of a second tricyclic alone or with SSRI? SSRI/ No Yes Nefaz | | (02) Add or replace Is this an with tricyclic; Atypical depression? consider Yes No venlafax/mirtaz | | (03) Adequate trial of MAOI? | (Bupropion may precede.) | No Yes | | | | Try MAOI (bupropion may | | precede) (04) | | This is a PHARMACOTHERAPY RESISTANT DEPRESSION More..(#4) 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 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 Try SSRI or Reconsider ECT? | tricyclic 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 DEPRESSION or lithium augmen- More..(#4) tation etc. (17) Bipolar depression | Urgent indication for ECT present? No Yes | | | ECT recommended. If refused or unsuccessful, | go on to the next question. | | 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) | | | | | 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]) This is a PHARMACOTHERAPY RESISTANT DEPRESSION | Melancholic type? non-melancholic melancholic (mood reactive) (mood non-reactive) | | | Melancholia Personality disorder? | | | | | | | Avoidant | | Borderline | | | Narcissistic | | | | Dependent | | | | | 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) 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]) 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]) | |||||||
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