Managing Depression In The Primary Care Setting
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Show notes:
Depression in the primary care setting – super common. Combine a shortage of mental health providers, months-long waiting lists, and increasing numbers of patients with symptoms, and it’s easy to see how depression is becoming a leading primary care health concern. If you feel unsure or unprepared for these patient encounters, you are in the right place.
Depression in Primary Care
This week, we’re taking some of the mystery out of working with patients with depression in the primary care setting and replacing it with practical approaches to helping patients. We’ll cover:
✅ Red flags of depression assessment, and how to handle them when you find them
✅ Key resources you need to know out at your clinic (and outside your clinic)
✅ What differentials to watch out for
✅ Approach to medications, and important factors to consider
There is an entire specialty track within the Nurse Practitioner world (PMHNP) that is designed to treat patients with mental health concerns. As Family Nurse Practitioners, there are limits to what is appropriate for us to treat – but with the right tools, some practice, and some preparation, we can certainly help our primary care patients experiencing this very common concern.
Resources mentioned in this episode:
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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confident, capable, and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff, you're in
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the right place.
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Make sure you subscribe and leave a review so you won't miss an episode.
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Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com
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slash podcast.
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Well, hey there, in this episode, we're going to be talking about depression, approach
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to assessment, as well as management principles.
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So when it comes to depression, I first things first want to talk about two things.
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One is about red flags, and two is about resources.
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And then we'll get into the assessment and the management pieces.
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So the first things first is we always want to assess for red flags of harm, whether
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self-harm or harm to others for that patient.
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I'm choosing my words wisely because I don't want this episode to get blocked
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off of the internet, so I don't actually know.
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But it's the same thing, SI, HI, harm to themselves, harm to other people.
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So we want to be assessing for that.
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There's a couple of different ways we can assess.
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Number one, we can just ask.
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We can just practice getting better at asking.
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I know it can be an uncomfortable question to ask, but it is the most important
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thing we can ask somebody who comes in with a complaint of depression.
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Another thing that we can do that can be helpful for asking, well, before I
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get into that, we want to ask if they have any thoughts of that, if they've had
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any of those thoughts before, if they've had any attempts before or
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hospitalizations before.
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And we also want to ask, if the answer is yes, we want to ask a couple more
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probing questions, like, do they have a plan?
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Do they have a timeline?
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Things like that.
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There's more structured approach.
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I can link to that down below, but we want to ask more context around it.
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And there is a fear sometimes that people have where if they ask those
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questions, it's going to prompt somebody to have those feelings or
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thoughts or desires, and that's just not the case.
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Our job is to assess for safety, and we have to do that, right?
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So the other piece of that though, are what are the resources you have?
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And this is something to think about preemptively before you're faced with
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this clinical situation, if you haven't yet been already.
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So I practice in the state of Massachusetts and we have a couple of
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supportive structures where I practice.
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One of them is there is actually a law that says if somebody is deemed
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to be like assessed and deemed to be a harm to themselves or others,
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they can be involuntarily hospitalized, like taken via ambulance to the
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hospital, and it's called section 12, and it's a longer name than that,
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but that's like the anecdotal name for it that we use in this area.
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And so it would be worth, it is worth looking into to see if that
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is a thing in your state.
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And I did a little quick Googling before I made this episode and it
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was a little confusing, so I would ask the people who we work with
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what the deal is, if they've ever encountered that.
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So that's one thing.
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Another thing, which again, is not necessarily like, it's not
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a punitive thing for patients.
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It's a support structure to make sure we keep patients safe.
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The other thing to think about is what are the resources you have
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in your area that are supportive to patients who have thoughts
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of self-harm or harm to others.
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And so in, in my state, there are a couple of different resources.
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There's a hotline for emergency services where they will come to the
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clinic when you call them as a clinician, or I believe patients can
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also call them at their home and get support services if they need them.
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You know, if they need to be quote unquote sectioned is the
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verbiage that we use in Massachusetts, at least is do they, are they
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at risk for harm to themselves?
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Do they need to be hospitalized?
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Another thing is that there are psychiatry resources where you
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can call a number and then it's almost like an e-consult where
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you can call a psychiatrist about whether it's a pediatric
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patient or an adult patient.
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And they can give you guidance about what's going on with a patient.
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I would also like, I would highly recommend, especially if you're
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newer in practice or if you haven't started yet, or if you're
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on the job search for sure, asking about what the resources are for
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the patients in your clinic.
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Do they have behavioral health therapists?
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Do you have an on-call behavioral health provider?
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Do they have a psychiatrist, physician, NPE, PA, et cetera?
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That's really, really helpful to know just to set yourself up for
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success before you need it.
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Cause if you wait till you need it, then it can be very uncomfortable.
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So those are the first kind of like disclaimer pieces about
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depression, right?
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Assessing for red flags of self-harm or harm to others.
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And then the other thing is about what your resources are.
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So let's get into the assessment piece though, and the management.
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So when it comes to assessment, I'm a family nurse practitioner.
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I do not have a psych mental health degree, although working
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in primary care has me wanting that.
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We've been really nice to do a dual degree because of the
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limited resources, unfortunately, that we have, at least in
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the clinics that I've practiced.
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But all of this stuff is just from the approach of a primary
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care provider, family nurse practitioner, and just doing our
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due diligence of safety and triage, and then calling and support
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when we need to.
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The reason I say that is that there can be some contention in
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the medical culture of, you know, what should we treat for
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psych mental illness in primary care versus what should be
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treated by a specialist.
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And the sad reality is that we don't have as many, don't
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have as many resources or access to resources as we need.
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So we just have to do our best to take care of our
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patients safely within our scope of practice, right?
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So when it comes to assessment of depression, a couple of
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supportive structures that can help us.
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One is assessment tools, right?
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So I am not, again, I'm not a psych mental health provider.
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I wish I was, their histories are way more in-depth than mine
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are, but I do my best.
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So starting with screeners can be a really helpful tool.
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So PHQ-9 is the screener tool of choice that I love.
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And it comes in multiple languages and it asks a variety
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of questions, all helps with the diagnostic criteria of
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depression, including asking about thoughts of self-harm
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or harm to others.
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And you get a score.
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So the scoring, the treatment goals, according to
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the psychiatrist that I used to work with, although
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there may be a guideline for this, PHQ-9 treatment goal
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is to be a four or less on average.
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And screenering tools are not necessarily diagnostic
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tools, right?
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But just they help us gather information.
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And then from there, there's mild, moderate and severe.
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So we want to kind of look and see, and I can
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link to that tool down below, what are those
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things, where to look for.
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And that can help as a diagnostic, help with
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diagnosis, but then also can help us assess how
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things are improving if their symptoms are deemed to
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be depression in fact.
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Two other screening tools I want to suggest or recommend.
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I've also made an episode about managing anxiety,
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where I believe I mentioned the screening tool,
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but GAD-7, the GAD-7, helps us to assess for anxiety.
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Is there comorbid anxiety going on or is it in
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fact truly anxiety, excuse me, in fact, truly
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anxiety versus straight up depression?
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Last tool that I want to recommend is something
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called the Moon Disorder Questionnaire.
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The MDQ.
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So again, a screening tool is not a diagnostic process
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necessarily.
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And the histories that I see from the psych providers
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are way more in depth than mine, but it's a
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good, it's a helpful place to start to assess for
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mood disorders, right?
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Because if you have an inclination that somebody
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has a mood disorder, we want to potentially veer away
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from things like SSRIs for management.
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So, you know, I'm not going to say that full
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acronym, you know SSRIs are.
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Um, so those are the places to start is the
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screening tools.
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The next piece is you want to assess, is there
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any underlying comorbidity that could be
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contributing to their symptoms, right?
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Do they have straight up depression?
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Do they have any psych comorbidities,
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depression, I'm sorry, anxiety, mood disorders,
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schizoaffective disorder, PTSD, et cetera,
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right?
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And I'm hoping to get a psychiatrist on the
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channel that can help us assessing for those
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things a little bit better than I currently do.
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But are we assessing for those psych comorbidities
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as well as medical comorbidities?
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There's a whole long laundry list of things
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that can be associated with depressive symptoms,
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not just diagnoses, but also medications.
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Globally speaking, we're talking about things
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that I kind of break it into body systems,
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So neurologically, we have to do a lot of
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neurologic assessment, right?
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Do they have any traumatic brain injury?
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Did they have a stroke?
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Do they have Parkinson's?
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Do they have seizure disorder?
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Things like that.
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So kind of like neurologically speaking,
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do they have any neurologic comorbidities?
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And again, another hack is like, if you
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just have somebody in front of you and
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you're like, I don't remember that
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laundry list, just, just, just start,
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just take a look at what else they have
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going on and what other symptoms they have
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going on.
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And then we can kind of assess, right?
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Other things are like endocrine disorders,
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various cardiology disorders.
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There's a whole, whole bunch of them,
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diabetes, things like that.
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So definitely consult your resources to
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kind of like look at that.
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I can link to some stuff down below,
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but we want to just think about what
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are the medical comorbidities as well
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as the psychiatric comorbidities that
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could be going on.
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There's a very high level approach to
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how to assess for depression, red
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flags, what are the support systems
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that you have?
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How do you assess for them?
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What are the screening tools?
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And then what are the potential
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comorbidities, right?
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If you walk away with nothing else
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from this episode, number one is,
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what are your resources?
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Are you assessing for harm?
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And what are the underlying
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comorbidities that this could be?
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So you don't miss anything that way
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and consulting those resources.
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Cause again, it's like a huge laundry
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list of potential comorbidities as
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well as potential medications.
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I don't think it's really supportive
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for me to like list them off in
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this episode because like that's
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probably going to be in one ear
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out the other.
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Or maybe that's just me.
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I prefer to like reference things
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at the time.
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But one way, if the main thing
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with primary care is what I try to
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do with management is I try to assess
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is somebody, this is straight up garden
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variety depression.
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Are there other comorbidities that I
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would not be safe for me to treat?
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Am I not sure if this is
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schizoaffective disorder?
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Am I not sure if there's a mood
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disorder here?
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And then I'm going to see what
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are the resources I have for an
246
00:10:21.010 --> 00:10:23.290
e-consult or like a quick
247
00:10:23.290 --> 00:10:25.190
consult curbside, whether in-house
248
00:10:25.190 --> 00:10:26.570
or a service that your clinic
249
00:10:26.570 --> 00:10:29.330
subscribes to, to get some
250
00:10:29.330 --> 00:10:30.310
support on that.
251
00:10:30.570 --> 00:10:31.930
But if you're pretty certain or
252
00:10:31.930 --> 00:10:33.070
if you are certain that it's, you
253
00:10:33.070 --> 00:10:36.170
know, first line depression,
254
00:10:36.590 --> 00:10:37.510
there's a couple of management
255
00:10:37.510 --> 00:10:38.710
principles I want to talk about.
256
00:10:39.470 --> 00:10:40.530
Whenever I talk about management
257
00:10:40.530 --> 00:10:42.310
in these episodes, whether the
258
00:10:42.310 --> 00:10:43.650
podcast or the YouTube channel,
259
00:10:43.890 --> 00:10:45.770
I really want to focus on broad
260
00:10:45.770 --> 00:10:47.990
approaches because so much of the
261
00:10:47.990 --> 00:10:49.170
details change.
262
00:10:49.730 --> 00:10:51.310
And these stay on for a while
263
00:10:51.310 --> 00:10:52.630
and I don't want to be advising
264
00:10:52.630 --> 00:10:54.050
outdated practices, right?
265
00:10:54.230 --> 00:10:55.150
So I'm going to talk about
266
00:10:55.150 --> 00:10:56.150
high level approach.
267
00:10:57.110 --> 00:10:58.670
So first step, if you're, if
268
00:10:58.670 --> 00:10:59.970
you're feeling confident, this is
269
00:10:59.970 --> 00:11:02.310
a garden variety, you know,
270
00:11:02.370 --> 00:11:03.930
plain major depressive disorder.
271
00:11:04.770 --> 00:11:06.530
We've assessed using the PHQ-9.
272
00:11:06.530 --> 00:11:08.910
You can kind of see, is it
273
00:11:08.910 --> 00:11:10.770
based on the results of the, of
274
00:11:10.770 --> 00:11:11.990
the scoring, you can see if it's
275
00:11:11.990 --> 00:11:13.870
mild, moderate or severe with a
276
00:11:13.870 --> 00:11:15.290
treatment goal of around four.
277
00:11:16.190 --> 00:11:17.290
You can use it for initial
278
00:11:17.290 --> 00:11:18.490
assessment as well as their
279
00:11:18.490 --> 00:11:19.910
follow-up assessments to see how
280
00:11:19.910 --> 00:11:20.590
they're doing.
281
00:11:21.330 --> 00:11:23.170
We can start with SSRIs.
282
00:11:23.490 --> 00:11:25.050
There's a whole bunch of options
283
00:11:25.050 --> 00:11:27.110
when it comes to SSRIs and
284
00:11:27.110 --> 00:11:31.250
you may find that you have
285
00:11:31.250 --> 00:11:32.550
preferences for one over the
286
00:11:32.550 --> 00:11:32.930
other.
287
00:11:33.210 --> 00:11:34.250
Typically when it comes to
288
00:11:34.250 --> 00:11:35.930
choosing an SSRI, I'm looking
289
00:11:35.930 --> 00:11:38.170
at what is the, what, what is
290
00:11:38.170 --> 00:11:39.630
it most studied for?
291
00:11:39.690 --> 00:11:40.690
Is it more studied for
292
00:11:40.690 --> 00:11:41.090
anxiety?
293
00:11:41.190 --> 00:11:42.030
Is it more studied for
294
00:11:42.030 --> 00:11:42.610
depression?
295
00:11:43.070 --> 00:11:44.650
Is it more helpful with sleep?
296
00:11:45.250 --> 00:11:47.030
Is it a long half-life?
297
00:11:47.150 --> 00:11:48.590
Is it a short half-life?
298
00:11:49.010 --> 00:11:49.690
Things like that.
299
00:11:49.730 --> 00:11:51.030
So I tend to avoid the shorter
300
00:11:51.030 --> 00:11:52.330
half-life medications because
301
00:11:52.330 --> 00:11:53.230
if they don't take it at
302
00:11:53.230 --> 00:11:54.950
the exact single, exact same
303
00:11:54.950 --> 00:11:56.250
time every day, they're going
304
00:11:56.250 --> 00:11:57.330
to have withdrawal symptoms
305
00:11:57.330 --> 00:11:58.510
and that's unpleasant.
306
00:11:59.630 --> 00:12:00.530
So I tend to go with the
307
00:12:00.530 --> 00:12:02.050
longer half-life options.
308
00:12:02.950 --> 00:12:04.370
Satellopram and S-satellopram,
309
00:12:04.370 --> 00:12:06.730
those are more apt for anxiety.
310
00:12:07.350 --> 00:12:08.370
You can use them for
311
00:12:08.370 --> 00:12:09.390
depression as well, but if
312
00:12:09.390 --> 00:12:10.930
you're going to have mixed
313
00:12:10.930 --> 00:12:12.410
comorbid anxiety and
314
00:12:12.410 --> 00:12:14.010
depression, you may decide to
315
00:12:14.590 --> 00:12:16.030
choose S-satellopram or
316
00:12:16.030 --> 00:12:16.790
S-satellopram.
317
00:12:17.310 --> 00:12:18.050
Things to remember about
318
00:12:18.050 --> 00:12:19.130
S-satellopram is that it
319
00:12:19.130 --> 00:12:21.270
has that QTC prolongation
320
00:12:21.270 --> 00:12:21.750
potentially.
321
00:12:22.150 --> 00:12:22.970
So something to keep in
322
00:12:22.970 --> 00:12:24.450
mind in terms of initial
323
00:12:24.450 --> 00:12:25.770
screen and follow-up and
324
00:12:25.770 --> 00:12:26.730
then thinking about their
325
00:12:26.730 --> 00:12:27.710
comorbidities, right?
326
00:12:28.210 --> 00:12:29.850
Sertraline is a great
327
00:12:29.850 --> 00:12:30.810
middle-of-the-road option
328
00:12:30.810 --> 00:12:31.930
for both depression and
329
00:12:31.930 --> 00:12:32.510
anxiety.
330
00:12:33.330 --> 00:12:34.550
I've anecdotally seen in
331
00:12:34.550 --> 00:12:35.390
practice that patients
332
00:12:35.390 --> 00:12:36.510
may feel a little bit
333
00:12:36.510 --> 00:12:37.910
sleepy with one, with that
334
00:12:37.910 --> 00:12:38.870
one more than the others.
335
00:12:39.210 --> 00:12:40.550
They might have more GI
336
00:12:40.550 --> 00:12:41.530
symptoms initially.
337
00:12:43.230 --> 00:12:44.010
And then there's a whole
338
00:12:44.010 --> 00:12:44.890
bunch of other options.
339
00:12:44.950 --> 00:12:45.810
Those are like the main
340
00:12:45.810 --> 00:12:46.690
ones that I tend to see
341
00:12:46.690 --> 00:12:47.430
in primary care though.
342
00:12:47.610 --> 00:12:48.530
Sertraline, S-satellopram,
343
00:12:48.610 --> 00:12:50.850
S-satellopram, and then
344
00:12:50.850 --> 00:12:52.350
some of the other SSRI
345
00:12:52.350 --> 00:12:52.950
options.
346
00:12:54.310 --> 00:12:54.710
Fluoxetine.
347
00:12:55.350 --> 00:12:56.150
Fluoxetine is the other
348
00:12:56.150 --> 00:12:56.990
one that I tend to see a
349
00:12:56.990 --> 00:12:57.770
little bit more of.
350
00:12:59.090 --> 00:12:59.790
Anyway, I'm trying not to
351
00:12:59.790 --> 00:13:00.650
use brand names, but
352
00:13:00.650 --> 00:13:01.690
there's two F ones.
353
00:13:01.690 --> 00:13:02.530
One of them has a short
354
00:13:02.530 --> 00:13:03.350
half-life and one that has
355
00:13:03.350 --> 00:13:04.250
a longer half-life, and I
356
00:13:04.250 --> 00:13:05.610
think fluoxetine does.
357
00:13:05.810 --> 00:13:06.510
Don't quote me on that.
358
00:13:07.170 --> 00:13:07.690
I don't want to say the
359
00:13:07.690 --> 00:13:07.970
brand name.
360
00:13:08.090 --> 00:13:08.650
I know the brand name,
361
00:13:08.670 --> 00:13:09.090
but I don't want to say
362
00:13:09.090 --> 00:13:09.570
it.
363
00:13:09.890 --> 00:13:11.170
So thinking about all of
364
00:13:11.170 --> 00:13:12.310
the profiles of them and
365
00:13:12.310 --> 00:13:12.870
like what's going on
366
00:13:12.870 --> 00:13:13.750
with your patient, which
367
00:13:13.750 --> 00:13:14.430
one would be the most
368
00:13:14.430 --> 00:13:14.870
supportive?
369
00:13:16.030 --> 00:13:16.930
A really important thing
370
00:13:16.930 --> 00:13:17.930
to talk about with patients
371
00:13:17.930 --> 00:13:18.770
when you're prescribing
372
00:13:19.310 --> 00:13:20.310
SSRIs is you want to
373
00:13:20.310 --> 00:13:21.250
talk about side effects.
374
00:13:21.970 --> 00:13:23.390
I always counsel them
375
00:13:23.390 --> 00:13:24.050
that, you know what?
376
00:13:24.050 --> 00:13:24.830
This can cause some
377
00:13:24.830 --> 00:13:25.430
side effects.
378
00:13:25.930 --> 00:13:26.650
Here they are.
379
00:13:26.730 --> 00:13:28.210
They can start mildly,
380
00:13:29.110 --> 00:13:29.830
more severe.
381
00:13:30.430 --> 00:13:31.070
We'll just see.
382
00:13:31.070 --> 00:13:32.470
They tend to be like you
383
00:13:32.470 --> 00:13:33.330
have them a little bit at
384
00:13:33.330 --> 00:13:34.030
first and then they tend
385
00:13:34.030 --> 00:13:34.450
to go away.
386
00:13:34.470 --> 00:13:36.470
Some people have a more
387
00:13:36.470 --> 00:13:37.810
significant reaction, a
388
00:13:37.810 --> 00:13:38.910
more marked reaction when
389
00:13:38.910 --> 00:13:39.710
they first start.
390
00:13:40.390 --> 00:13:41.310
Just let me know how
391
00:13:41.310 --> 00:13:41.790
you're doing.
392
00:13:42.390 --> 00:13:43.310
The other thing I let
393
00:13:43.310 --> 00:13:44.310
them know though is
394
00:13:44.310 --> 00:13:45.150
whenever we choose a
395
00:13:45.150 --> 00:13:47.010
medication for depression
396
00:13:47.010 --> 00:13:50.150
is that we start at the
397
00:13:50.150 --> 00:13:51.570
lowest dose and we work
398
00:13:51.570 --> 00:13:52.650
our way up and it takes
399
00:13:52.650 --> 00:13:53.630
about four to six weeks
400
00:13:53.630 --> 00:13:54.770
to see a full effect.
401
00:13:55.610 --> 00:13:56.570
When they start off
402
00:13:56.570 --> 00:13:57.530
knowing that this might
403
00:13:57.530 --> 00:13:58.570
not be the right choice
404
00:13:58.570 --> 00:14:00.030
for them, we are going
405
00:14:00.030 --> 00:14:00.530
to start at the lowest
406
00:14:00.530 --> 00:14:01.190
dose. You might not see
407
00:14:01.190 --> 00:14:02.030
results right away.
408
00:14:02.450 --> 00:14:03.230
We might have to change
409
00:14:03.230 --> 00:14:03.910
because of side effects.
410
00:14:03.910 --> 00:14:04.730
When they know that
411
00:14:04.730 --> 00:14:05.810
going in, it's potentially
412
00:14:05.810 --> 00:14:07.090
less discouraging for
413
00:14:07.090 --> 00:14:08.990
them later on versus
414
00:14:08.990 --> 00:14:09.910
like if you didn't
415
00:14:09.910 --> 00:14:10.550
counsel them in the
416
00:14:10.550 --> 00:14:11.490
first place, they're
417
00:14:11.490 --> 00:14:12.210
like, what is going
418
00:14:12.210 --> 00:14:12.630
on here?
419
00:14:12.630 --> 00:14:13.330
This is just not
420
00:14:13.330 --> 00:14:13.810
working for me.
421
00:14:13.810 --> 00:14:14.330
I'm not going to try
422
00:14:14.330 --> 00:14:15.110
medications and then
423
00:14:15.110 --> 00:14:16.190
they leave and then
424
00:14:16.190 --> 00:14:16.990
they don't get support.
425
00:14:17.290 --> 00:14:17.450
Right.
426
00:14:17.470 --> 00:14:18.590
So I try to really be
427
00:14:18.590 --> 00:14:19.290
mindful about that
428
00:14:19.290 --> 00:14:20.290
counseling initially for
429
00:14:20.290 --> 00:14:22.050
them so that they can
430
00:14:22.050 --> 00:14:23.310
feel empowered and have
431
00:14:23.310 --> 00:14:24.690
more success potentially
432
00:14:24.690 --> 00:14:25.150
with it.
433
00:14:25.850 --> 00:14:26.430
A couple of caveats
434
00:14:26.430 --> 00:14:27.090
about that.
435
00:14:27.270 --> 00:14:28.430
Not everybody responds
436
00:14:28.430 --> 00:14:30.350
to the SSRI that you've
437
00:14:30.350 --> 00:14:31.210
chosen initially.
438
00:14:31.530 --> 00:14:32.150
So if they're not
439
00:14:32.150 --> 00:14:33.090
responding, especially
440
00:14:33.090 --> 00:14:34.010
as you go up on the
441
00:14:34.010 --> 00:14:35.750
dose every four, I
442
00:14:35.750 --> 00:14:36.650
give it at least like
443
00:14:36.650 --> 00:14:37.670
four-ish weeks to
444
00:14:37.670 --> 00:14:39.030
start, depending on
445
00:14:39.030 --> 00:14:39.690
how severe their
446
00:14:39.690 --> 00:14:40.370
symptoms are.
447
00:14:40.410 --> 00:14:41.130
If it's two to four
448
00:14:41.130 --> 00:14:43.110
weeks, if it's, yeah,
449
00:14:43.310 --> 00:14:44.370
I tend to do, it
450
00:14:44.370 --> 00:14:44.910
takes about four to
451
00:14:44.910 --> 00:14:45.630
six weeks to take a
452
00:14:45.630 --> 00:14:46.070
full effect.
453
00:14:46.370 --> 00:14:47.290
They may start seeing
454
00:14:47.290 --> 00:14:48.070
things at two weeks.
455
00:14:48.070 --> 00:14:49.050
So I might do two
456
00:14:49.050 --> 00:14:50.310
weeks dose increase
457
00:14:50.310 --> 00:14:50.990
at four weeks.
458
00:14:50.990 --> 00:14:51.610
If I know they're
459
00:14:51.610 --> 00:14:52.210
going to need to go
460
00:14:52.210 --> 00:14:52.910
up on the dose
461
00:14:52.910 --> 00:14:54.190
because the depression
462
00:14:54.190 --> 00:14:55.130
is really severe.
463
00:14:56.010 --> 00:14:57.250
But I tend to, I
464
00:14:57.250 --> 00:14:58.070
tend to follow that
465
00:14:58.070 --> 00:14:58.950
approach with them.
466
00:14:58.950 --> 00:15:00.470
If they're not responding,
467
00:15:00.550 --> 00:15:01.170
especially as the
468
00:15:01.170 --> 00:15:02.170
dose is going up or
469
00:15:02.170 --> 00:15:02.790
they're having side
470
00:15:02.790 --> 00:15:03.530
effects, you may need
471
00:15:03.530 --> 00:15:04.230
to change to a
472
00:15:04.230 --> 00:15:05.090
different SSRI.
473
00:15:05.470 --> 00:15:06.590
Not everybody responds
474
00:15:06.590 --> 00:15:07.050
to the one that
475
00:15:07.050 --> 00:15:08.090
you've chosen, right?
476
00:15:08.670 --> 00:15:10.150
Another option after
477
00:15:10.150 --> 00:15:11.830
you've switched SSRIs,
478
00:15:11.830 --> 00:15:12.610
you could change to
479
00:15:12.610 --> 00:15:13.710
an, a different option
480
00:15:13.710 --> 00:15:14.510
category, second
481
00:15:14.510 --> 00:15:15.190
line option.
482
00:15:15.670 --> 00:15:16.770
You could either do
483
00:15:16.770 --> 00:15:18.730
a combined therapy.
484
00:15:19.050 --> 00:15:19.990
You could switch to
485
00:15:19.990 --> 00:15:20.610
a different category
486
00:15:20.610 --> 00:15:21.310
of medication, or you
487
00:15:21.310 --> 00:15:22.090
can do combined
488
00:15:22.090 --> 00:15:23.370
therapy where you
489
00:15:23.370 --> 00:15:25.250
can consider adding
490
00:15:25.250 --> 00:15:26.090
one that will
491
00:15:26.090 --> 00:15:27.210
augment the effects
492
00:15:28.430 --> 00:15:29.730
or change altogether.
493
00:15:30.270 --> 00:15:30.410
Right.
494
00:15:30.410 --> 00:15:30.850
And this is getting
495
00:15:30.850 --> 00:15:31.650
a little bit, a
496
00:15:31.650 --> 00:15:32.330
little bit nuanced
497
00:15:32.330 --> 00:15:33.650
for a shorter episode
498
00:15:33.650 --> 00:15:34.250
on the podcast
499
00:15:34.250 --> 00:15:35.030
on the YouTube channel.
500
00:15:35.050 --> 00:15:35.630
So I'll kind of
501
00:15:35.630 --> 00:15:36.590
keep it high level,
502
00:15:36.710 --> 00:15:38.030
but generally second
503
00:15:38.030 --> 00:15:39.790
line after SSRIs
504
00:15:39.790 --> 00:15:41.490
are things like SNRIs.
505
00:15:41.590 --> 00:15:42.950
So non SSRI
506
00:15:43.710 --> 00:15:44.090
antidepressants,
507
00:15:44.530 --> 00:15:45.190
like bupropion.
508
00:15:45.450 --> 00:15:46.550
And then sometimes
509
00:15:46.550 --> 00:15:48.670
there's also some of
510
00:15:48.670 --> 00:15:49.410
those can be combined
511
00:15:49.410 --> 00:15:51.030
with SSRIs, not all of them.
512
00:15:51.030 --> 00:15:51.450
I'm not going to
513
00:15:51.450 --> 00:15:52.550
get into specifics, right?
514
00:15:52.550 --> 00:15:53.130
Just keeping it
515
00:15:53.130 --> 00:15:53.830
high level here.
516
00:15:53.950 --> 00:15:54.990
And then you may also
517
00:15:54.990 --> 00:15:56.090
see, especially if they
518
00:15:57.110 --> 00:15:58.070
transfer to a higher
519
00:15:58.070 --> 00:15:58.990
level of care, if they're
520
00:15:58.990 --> 00:16:00.410
not responding to
521
00:16:00.410 --> 00:16:01.890
an initial medication,
522
00:16:02.190 --> 00:16:03.250
dose increase, switch
523
00:16:03.250 --> 00:16:04.510
to a different medication,
524
00:16:04.930 --> 00:16:06.450
switch classes altogether.
525
00:16:06.910 --> 00:16:08.270
They may need to have
526
00:16:08.270 --> 00:16:09.430
something augmented,
527
00:16:09.990 --> 00:16:10.930
whether you can do
528
00:16:10.930 --> 00:16:11.710
that in primary care
529
00:16:11.710 --> 00:16:13.090
or you can do that
530
00:16:13.090 --> 00:16:14.090
with a specialist.
531
00:16:14.230 --> 00:16:15.090
That's really kind of
532
00:16:15.090 --> 00:16:16.510
up to your personal
533
00:16:16.510 --> 00:16:17.730
practice preference,
534
00:16:17.950 --> 00:16:19.030
your scope, the
535
00:16:19.030 --> 00:16:20.070
culture of your clinic.
536
00:16:20.350 --> 00:16:20.610
Right.
537
00:16:20.610 --> 00:16:21.150
So I'm not going to
538
00:16:21.150 --> 00:16:21.730
get into super
539
00:16:21.730 --> 00:16:22.730
those specifics because
540
00:16:22.730 --> 00:16:23.990
again, safety first.
541
00:16:24.210 --> 00:16:24.690
I always think about
542
00:16:24.690 --> 00:16:25.630
safety first, especially
543
00:16:25.630 --> 00:16:26.490
when I make these
544
00:16:26.490 --> 00:16:27.690
episodes as well.
545
00:16:27.910 --> 00:16:28.510
I don't want to be
546
00:16:28.510 --> 00:16:29.410
giving guidance about
547
00:16:29.410 --> 00:16:30.290
a patient and what
548
00:16:30.290 --> 00:16:30.970
doses to choose,
549
00:16:30.990 --> 00:16:31.810
what medications to
550
00:16:31.810 --> 00:16:32.750
choose out of context.
551
00:16:33.090 --> 00:16:33.710
So basically the
552
00:16:33.710 --> 00:16:34.550
general principles
553
00:16:34.550 --> 00:16:35.930
when it comes to SSRIs
554
00:16:35.930 --> 00:16:36.970
are you choose one
555
00:16:36.970 --> 00:16:38.130
to start based on
556
00:16:38.130 --> 00:16:39.370
their symptom profile,
557
00:16:39.430 --> 00:16:40.510
as well as the profile
558
00:16:40.510 --> 00:16:41.130
of the medications.
559
00:16:41.130 --> 00:16:41.970
As you become more
560
00:16:41.970 --> 00:16:43.030
familiar with them,
561
00:16:43.590 --> 00:16:44.670
you started a low dose,
562
00:16:44.870 --> 00:16:45.950
increase that dose,
563
00:16:46.010 --> 00:16:47.070
see how they respond,
564
00:16:47.250 --> 00:16:47.750
see how, if they
565
00:16:47.750 --> 00:16:48.650
have any side effects,
566
00:16:48.770 --> 00:16:49.870
the next one is you
567
00:16:49.870 --> 00:16:50.930
can switch to a different
568
00:16:50.930 --> 00:16:51.910
SSRI if they're not
569
00:16:51.910 --> 00:16:53.870
responding and, or you
570
00:16:53.870 --> 00:16:55.030
can switch to another
571
00:16:55.030 --> 00:16:55.890
category altogether.
572
00:16:56.070 --> 00:16:57.210
That's not an SSRI.
573
00:16:57.950 --> 00:16:58.790
So the second line
574
00:16:58.790 --> 00:17:00.470
options are things like
575
00:17:01.990 --> 00:17:03.350
SNRIs, duloxetine,
576
00:17:03.530 --> 00:17:05.849
phenyfaxine, non SSRI
577
00:17:05.849 --> 00:17:07.290
antidepressants like
578
00:17:07.290 --> 00:17:08.089
mupropion.
579
00:17:09.450 --> 00:17:10.670
There is another
580
00:17:10.670 --> 00:17:11.890
option though of
581
00:17:11.890 --> 00:17:13.650
combination of variety
582
00:17:13.650 --> 00:17:14.290
of different types
583
00:17:14.290 --> 00:17:15.470
of medications to augment.
584
00:17:15.530 --> 00:17:16.190
If you're having a
585
00:17:16.190 --> 00:17:17.490
partial response with
586
00:17:17.490 --> 00:17:18.569
some other agents,
587
00:17:18.569 --> 00:17:19.430
it's getting a little
588
00:17:19.430 --> 00:17:20.630
sophisticated for this
589
00:17:20.630 --> 00:17:22.569
episode because I don't
590
00:17:22.569 --> 00:17:23.530
want to give advice
591
00:17:23.530 --> 00:17:25.010
about specific patients.
592
00:17:25.010 --> 00:17:26.670
Without the context of
593
00:17:26.670 --> 00:17:28.050
the full picture rate,
594
00:17:28.369 --> 00:17:29.230
but general management
595
00:17:29.230 --> 00:17:30.770
principles are things
596
00:17:30.770 --> 00:17:32.530
like augmented options
597
00:17:32.530 --> 00:17:33.450
that typically you'll
598
00:17:33.450 --> 00:17:34.430
see the psychiatric
599
00:17:34.430 --> 00:17:35.350
providers do.
600
00:17:35.690 --> 00:17:36.650
I feel comfortable
601
00:17:36.650 --> 00:17:38.030
adding some of them on,
602
00:17:38.250 --> 00:17:38.630
but again, I'm not
603
00:17:38.630 --> 00:17:39.030
going to get into
604
00:17:39.030 --> 00:17:40.510
details here, but things
605
00:17:40.510 --> 00:17:42.470
like buspirone,
606
00:17:42.890 --> 00:17:43.850
erypiprazole, those
607
00:17:43.850 --> 00:17:44.830
kind of like a typical
608
00:17:44.830 --> 00:17:46.070
antipsychotics,
609
00:17:47.270 --> 00:17:48.450
olanzapine, things
610
00:17:48.450 --> 00:17:49.010
like that.
611
00:17:49.310 --> 00:17:50.550
You may see those
612
00:17:50.550 --> 00:17:51.950
as augmenters to help
613
00:17:52.410 --> 00:17:53.390
SSRIs that are
614
00:17:53.390 --> 00:17:54.590
partially responding work,
615
00:17:54.590 --> 00:17:55.690
but I really want to
616
00:17:55.690 --> 00:17:56.650
keep it to the basics
617
00:17:56.650 --> 00:17:57.670
here of this episode
618
00:17:57.670 --> 00:17:58.550
because if you're
619
00:17:58.550 --> 00:17:59.570
getting into that place,
620
00:17:59.710 --> 00:18:00.270
especially as a
621
00:18:00.270 --> 00:18:01.130
newer grad, I really
622
00:18:01.130 --> 00:18:02.110
recommend, number one,
623
00:18:02.130 --> 00:18:03.570
utilizing your resources,
624
00:18:04.010 --> 00:18:04.550
collaborating with
625
00:18:04.550 --> 00:18:05.730
your supervising provider,
626
00:18:06.170 --> 00:18:06.830
collaborating with
627
00:18:06.830 --> 00:18:07.950
psychiatric providers,
628
00:18:08.290 --> 00:18:09.590
and just always
629
00:18:09.590 --> 00:18:10.490
doing safety first.
630
00:18:10.630 --> 00:18:11.170
Like we really,
631
00:18:11.290 --> 00:18:12.050
it's not just about
632
00:18:12.050 --> 00:18:12.850
knowing what medications
633
00:18:12.850 --> 00:18:13.650
you can add.
634
00:18:13.830 --> 00:18:14.970
You have to understand
635
00:18:14.970 --> 00:18:15.710
the medications,
636
00:18:15.870 --> 00:18:16.590
the side effects,
637
00:18:16.670 --> 00:18:17.230
the effectiveness,
638
00:18:17.370 --> 00:18:18.010
how to dose them,
639
00:18:18.030 --> 00:18:18.850
how to titrate them,
640
00:18:18.910 --> 00:18:19.810
how to comb all of them.
641
00:18:19.930 --> 00:18:20.090
Right?
642
00:18:20.090 --> 00:18:21.190
There's like a lot to know.
643
00:18:21.390 --> 00:18:22.210
So I just don't want to
644
00:18:22.210 --> 00:18:23.290
try to cram all of that
645
00:18:23.290 --> 00:18:24.510
into one little episode,
646
00:18:24.510 --> 00:18:25.210
but just hopefully
647
00:18:25.210 --> 00:18:26.010
that'll be a helpful
648
00:18:26.010 --> 00:18:27.510
primer for you of like,
649
00:18:27.530 --> 00:18:29.310
where do I go from here
650
00:18:29.310 --> 00:18:30.230
with each of those?
651
00:18:30.650 --> 00:18:32.730
So if you have not grabbed
652
00:18:32.730 --> 00:18:33.750
the ultimate resource
653
00:18:33.750 --> 00:18:34.810
guide for the new NP,
654
00:18:34.990 --> 00:18:37.170
head over to realworldnp.com
655
00:18:37.170 --> 00:18:38.030
slash guide.
656
00:18:38.650 --> 00:18:39.870
You'll get these episodes
657
00:18:39.870 --> 00:18:40.610
and treat your inbox
658
00:18:40.610 --> 00:18:41.470
every week with notes
659
00:18:41.470 --> 00:18:42.610
from me, patient stories
660
00:18:42.610 --> 00:18:43.590
and bonuses I really
661
00:18:43.590 --> 00:18:44.470
just don't share
662
00:18:44.470 --> 00:18:45.170
anywhere else.
663
00:18:45.250 --> 00:18:45.950
Thank you so much
664
00:18:45.950 --> 00:18:46.770
for tuning in.
665
00:18:46.790 --> 00:18:47.370
Hang in there
666
00:18:47.370 --> 00:18:48.190
and I'll see you soon.
667
00:18:51.640 --> 00:18:53.260
That's our episode for today.
668
00:18:53.400 --> 00:18:54.440
Thank you so much
669
00:18:54.440 --> 00:18:55.140
for listening.
670
00:18:55.580 --> 00:18:56.960
Make sure you subscribe
671
00:18:56.960 --> 00:18:57.900
leave a review
672
00:18:57.900 --> 00:18:59.780
and tell all your NP friends
673
00:18:59.780 --> 00:19:01.240
so together we can help
674
00:19:01.240 --> 00:19:02.720
as many nurse practitioners
675
00:19:02.720 --> 00:19:04.700
as possible, give the best care
676
00:19:04.700 --> 00:19:05.500
to their patients.
677
00:19:05.920 --> 00:19:07.380
If you haven't gotten your copy
678
00:19:07.380 --> 00:19:08.860
of the ultimate resource guide
679
00:19:08.860 --> 00:19:10.020
for the new NP,
680
00:19:10.340 --> 00:19:12.620
head over to realworldnp.com
681
00:19:12.620 --> 00:19:13.520
slash guide.
682
00:19:13.880 --> 00:19:15.260
You'll get these episodes
683
00:19:15.260 --> 00:19:16.420
sent straight to your inbox
684
00:19:16.420 --> 00:19:17.860
every week with notes
685
00:19:17.860 --> 00:19:19.440
from me, patient stories
686
00:19:19.440 --> 00:19:20.640
and extra bonuses.
687
00:19:20.880 --> 00:19:21.700
I really just don't
688
00:19:21.700 --> 00:19:22.780
share anywhere else.
689
00:19:23.100 --> 00:19:24.160
Thank you so much again
690
00:19:24.160 --> 00:19:24.740
for listening.
691
00:19:24.900 --> 00:19:26.160
Take care and talk soon.
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