E5 - Depression Decisions: To SSRI or SNRI, that is the question... sometimes

Come learn about the do’s and don’ts of depression. In this episode, Dr. Miracle and Dr. Hendratta deep dive into depression. They discuss everything from why we need to treat it, how to diagnose it, and its different treatment modalities. Whether you are a seasoned psychiatrist who treats depression on a daily basis and are looking for a chance to refresh your knowledge, or are a third year medical student getting ready to start your first psychiatry rotation, you don’t want to miss out. Depression decisions need to be made and this podcast can help you make them! 

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Transcript

Thanh: 0:01

Welcome to the Y in Psychiatry,

Dr. Amayo: 0:03

Hi, this is Dr. Amayo C/L fellow.

Thanh: 0:06

Where we delve into the intricate nuances of psychiatric topics.

Dr. Handratta: 0:10

My name is Dr. Handratta attending psychiatrist. I did my residency from University of Connecticut and then I did my fellowship from Georgetown University in consultation and liaison.

Thanh: 0:20

Each episode features interview style discussions that explore the intersection of the mind medicine and the human experience. Together we'll uncover the hidden why and the groundbreaking discovery shaping the psychiatric landscape. So grab a seat, warm beverage, tune in, and let's embark on this journey to unlock the mysteries of the human psyche. Only on The Y in Psychiatry.

Dr. Amayo: 0:47

Welcome back to the Y in psychiatry. It is your host, Dr. Amayo, CL fellow and I'm here with...

Dr. Handratta: 0:53

Dr. Handratta.

Dr. Amayo: 0:55

Yes. And so today we are going to be talking about depression but we're gonna be talking about the algorithm of depression. So it dawned on us that we came off firing. We talked about the neuro circuitry related to depression. We talked about the fun new drugs, ketamine and vortioxetine. And today we are gonna slow things down and start from the top. And our first question is, why should we treat depression? Why do we exist? To treat depression asking all the tough questions.

Dr. Handratta: 1:30

The reason we treat depression is because we know depression causes a decrease in the quality of life, both for the patient as well as the caregiver. Depression also can make you non-compliant, especially if you have comorbid medical conditions. Or your medical condition that has led to comorbid depression. Depression can actually decrease the compliance with the medication, physical therapy, as well as recovery after surgery. Plus depression is also a risk factor. Untreated long-term depression is a risk factor for the development of dementia.

Dr. Amayo: 2:02

Do we know why?

Dr. Handratta: 2:03

The reason being is that in depression, we know there is an increase in the level of stress hormone that we call as glucocorticoids, and when the glucocorticoids are increased. There is a glucocorticoid resistance in depression. The glucocorticoid can actually have adverse effects on your brain, which we call as neural adaptation, so it causes a decrease in the dendritic spines in your prefrontal cortex and hippocampus, and increase in the dendritic spine in your limbic area like amygdala, so your limbic area becomes disinhibited. So the prefrontal cortex has no longer control over your limbic system. And when you have loss of dendritic spine in your hippocampus, that can lead to a lot of cognitive impairment.

Dr. Amayo: 2:46

And this is because of that state of elevated glucocorticoids. So if someone has like Cushing's syndromes, do they have similar risks to dementia?

Dr. Handratta: 2:54

So patients with Cushings syndrome, we know more than 50% of them suffer from depression. Plus, Long-term elevated glucocorticoids does lead to cognitive impairment in patients with Cushing's syndrome.

Dr. Amayo: 3:05

All right. Basically why to treat depression? It improves quality of life. If they have other comorbid issues, the depression, having depression reduces their function and reduces their long term. Prognosis. And then the big one, which I think about for our patients and even us is it having depression increases your risk of dementia. In the long term. And that's because of the increased in gluococorticoids leading to reduction of dendritic spines in the frontal lobe and increase of dendritic spine in the limbic system. Okay. And so the next then is just simple How do we diagnose? Oh, we are, I think hopefully everyone listening to this podcast know how to diagnose depression. Hopefully everyone has studied their DSM fives, TR but what key takeaway would you say we should know for diagnosing depression?

Dr. Handratta: 3:53

So it's easy to diagnose depression, right? So you have to just follow the DSM criteria, or you have the PHQ nine. So I believe in using scales. Because scales helps you to diagnose it. Plus it also helps to see how the patient is responding to the treatment, whether it's pharmacotherapy or psychotherapy. once you diagnose depression, few things to keep in mind is that we have to rule out bipolar disorder, Because if you look at the data, a patient who visits primary care physician, according to the data out of every five patients who have been diagnosed with depression in a primary care clinic, one will have undiagnosed bipolar disorder, So it's missed. And plus most of the patients with bipolar disorder, presents with depression. So it's extremely important actually to look at the risk factors for bipolar depression, as well as doing a mood disorder questionnaire, which we call as M D Q. Or you can actually use something called as a rapid mood screener. So rapid mood screener is a shorter version. And has a very good sensitivity and specificity. So if they are positive, that means that there is an increased likelihood of bipolar disorder. So you have to go in depth, If it's negative means that the patient doesn't have bipolar disorder so then you can move forward. Then you also have to rule out comorbid medical conditions that can cause depression. Like for example, Cushings or patients who have chronic conditions like cancer, rheumatological condition, which causes cytokine induced depression, Because you have to treat the underlying condition for the depression to get better, or you have to also treat the depression simultaneously to improve the compliance with treatment, right? Or the medical condition. Another thing we commonly miss is diagnosing sleep apnea. A lot of times we ask questions about sleep, but we forget to ask about sleep apnea. untreated sleep apnea can cause depression, So that is something to look for. And then ordering basic labs like cbc, cmp, urine toxicology, thyroid function, vitamin b12, folate, vitamin D, and if appropriate, ordering R P R and H I V, depending upon the patient population.

Dr. Amayo: 5:55

Does obesity increase your risk for depression?

Dr. Handratta: 5:57

yes, so there is a good question. So there are some studies which talk about obesity. So your adipose tissue produces about 30% of inflammatory cytokine called interleukin six, which can cause something called"sickness behavior" and the difference between cytokine induced depression. And major depressive disorder is that cytokine induced depression is mostly associated with anorexia and psychomotor retardation. And there is less feeling of guilt involved in cytokine induced depression. But yes, obesity can increase the risk of depression, so stay away from medications that can increase weight gain.

Dr. Amayo: 6:36

Okay, so key pearls for diagnosing depression. Biggest thing, rule out bipolar disorder. And the MDQ' and the RMS. Are those free? Can you like Google them, get them?

Dr. Handratta: 6:48

Yes you can.

Dr. Amayo: 6:49

Okay. Good scales to use. Quick scales with high sensitivity to help you rule those out. Keep note of medical conditions which can mask as depression or would not get better if you don't want depression. And one big one is obesity and sleep apnea. Those seems to be missed. And obesity causes more likely cytokine induced depression with interleukin six elevation. And then get your basic labs. And that would also probably help with the hypothyroidism, which is another medical condition that can present as depression.

Dr. Handratta: 7:19

That's right. And Dr. Amayo I have forgot about substance use disorders and medications that can induce depression like high dose of steroids, long-term use of steroids can cause depression. So we need to look at that as well as benzodiazepines can also cause depression. Okay. Yeah. So you have look at medication induced depression as well as substance induced depression.

Dr. Amayo: 7:38

Okay. So I think we have why to treat and we have how to diagnosis or things to keep an eye out for when we are diagnosing depression. Let's go to, How would you treat depression? What's your first line? First line medication for treating depression.

Dr. Handratta: 7:53

So the first line medication for treatment or depression.

Dr. Amayo: 7:56

Ketamine.

Dr. Handratta: 7:56

Hahahah, I wish actually that was the first line treatment, right? Yeah so the first line treatment of depression still is SSRI as well as SNRI. And these are age old medications. A lot of them actually work very similar to each other except the side effect profile, as well as the way they are metabolized in the body, So that those are the difference But the mechanism of action of most of the SSRI and SNRI are very similar to each other. Most of the SNRIs will work like other SNRI. SSRI will work like other SSRIs. Now, if the patient does not respond to these medications, then you can also use vortioxetine. Which is a newer generation antidepressant, which is not like a me too an anti-depressant. It works in a very different mechanism. It does hit the transporter, but it also hits the postsynaptic receptors.

Dr. Amayo: 8:45

And if you subscribe to our channel, you would've learned about vortioxetine in the last episode. You mentioned if SSRIs or SNRI doesn't work, how would you know when they're not working?

Dr. Handratta: 8:56

So again, we do a PHQ nine at baseline. Okay? So we know what our baseline PHQ nine scores are, and then when you use this antidepressant at an optimal dose like for example, escitalopram, like anywhere between 10 and 20 milligram citalopram actually between 20 and 40 milligrams or sertraline between 100 and 200 milligrams, right? When you use it at a good therapeutic dosage, in about two to four weeks, you should see at least a 20% improvement in your PHQ nine scores. That actually has a moderate positive predictive value that this patient is going to respond to this medication when you continue the treatment for another six to eight weeks. We are looking for remission, 70% improvement in those symptoms. Suppose that your PHQ nine score is less than 20% improvement in about two to four weeks at an optimal dose that has a very strong positive predictive value that the medications aren't gonna work. So it's a good idea to switch to another treatment, which could actually be from an SSRI to an SNRI or from an SNRI to an SSRI. Or if you have used both of them either to vortioxetine or Bupropion or mirtazapine. So you can actually like switch between the class.

Dr. Amayo: 10:08

Okay. So first line treatment for depression, SSRIs or SNRIs and, get a PHQ nine. See if in two to four weeks, let's say 20% decrease in symptoms, if not, seems like it's most likely that they wouldn't respond to that. especially depending on their symptoms and how severe their dysfunction is. Maybe that would be time to switch to either to a different class, SSRI, SNRI, or vortioxetine or bupropion or mirtazapine and what would be your second line?

Dr. Handratta: 10:37

So suppose I started SSRI and the patient does not respond either because it's not effective or because of the side effects. Then I usually switch to an SNRI. That's my second. And if they do not respond to an SNRI due to it's not effective or side effects, then I basically use Vortioxetine. Okay. Because you need to try an SSRI SNRI before the insurance company can approve vortioxetine. I also use vortioxetine if a person has depression and also has some cognitive issues. Because we know that according to research data, vortioxetine helps with cognitive functioning, though it's not FDA recommended for improvement, cognitive symptoms. Okay. So I want people to realize that. So it's not FDA approved for cognitive dysfunction. And if they fail to respond to vortioxetine, then I might actually use bupropion. More effective for patients with depression, with comorbid nicotine use disorder. Okay. Smoking cigarettes, or they also have comorbid ADHD where Bupropion can be used as an off-label treatment. And if they don't respond to that, then I can actually go to mirtazapine. But with mirtazapine the problem is weight gain. Yeah. And as we spoke, weight gain can actually increase the risk for depression. And plus can also make obstructive sleep apnea worse.

Dr. Amayo: 11:48

So mirtazapine would probably be good for someone that has the anorexia, symptoms with their depression. So maybe it's for someone with, cytokine induced depression?

Dr. Handratta: 11:57

You can use that actually mirtazapine you can use in cytokine induced depression if the patient is losing a lot of weight. Yeah, definitely. You can go with mirtazapine. And we'll talk about each SSRI where it can be used. Like what's special about different SSRIs and SNRIs.

Dr. Amayo: 12:11

I think that's all we have for today in The Y in Psychiatry. So we talked about why to treat depression. We talked about how to diagnose depression. Don't forget about bipolar disorder. Don't forget about sleep apnea. Don't forget about obesity. And we talked about first line SSRIs, SNRIs, and if that doesn't work, you can try vortioxetine. It's also bupropion and mirtazapine, depending on the patient presentation. Thank you all.

Dr. Handratta: 12:36

Thank you all. Now we are ready to actually go and eat some meatballs.

Katrina: 12:42

Thank you for joining us on today's episode. Our tireless team is already hard at work, cobbling together another potpourri of fascinating discussion for next week, so be sure to tune in, visit our website and our podcast feed and let us know your thoughts on the episode. Subscribe so you don't miss our releases every Wednesday. Until next time, keep smiling, keep shining, and stay curious.