CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS 

Office of the Chief Medical Officer 
Clinical Operations 


Antidepressant Medications 

Med-2
 
Category: Medication Use 
Published Date: May 2021
  1. GENERAL CONSIDERATIONS FOR USE
    1. Antidepressant medication trial should be considered during depressive mood episodes of moderate or severe intensity in patients with a diagnosis of:
      1. Major Depressive Disorder
      2. Bipolar I Disorder
      3. Bipolar II Disorder
      4. Schizoaffective Disorder, Depressive Type
      5. Schizoaffective Disorder, Bipolar Type
    2. Selection of antidepressants for sequential trials should be based upon:
      1. Availability,
      2. Clinical judgment,
      3. Side effect profile,
      4. Presence of other general medical conditions,
      5. Other concurrent medications,
      6. Client preference,
      7. Potential toxicity, and
      8. Information regarding adequacy and outcome of previous treatment with other antidepressant medications.
    3. It may be preferable to select antidepressants from classes with different mechanisms of action and/or metabolic pathways than those that have previously proved ineffective.
    4. Tricyclic antidepressants and Monoamine oxidase inhibitors (MAOIs):
      1. Should not be used as a first-line treatment due to their potential medical side effects (e.g., cardiovascular side effects). 
      2. Should be used when:
        1. Other antidepressant medications are contraindicated,
        2. Other antidepressant medications are ineffective or unavailable, or
        3. Clients are already stabilized and doing well on a tricyclic antidepressant or MAOI.
    5. Determination of which Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) should be used first is based upon:
      1. Availability,
      2. Clinical judgment,
      3. Presence of other general medical conditions,
      4. Other concurrent medications,
      5. Client preference, and
      6. Likelihood of adequate amenability.
    6. When a non-tricyclic antidepressant is poorly tolerated or ineffective after an adequate clinical trial, the individual may be switched to a different antidepressant selected based on clinical judgment.
    7. Electroconvulsive Therapy (ECT) should be considered:
      1. For the treatment of a major depressive disorder that does not respond sufficiently to two (2) adequate trials of antidepressant medications,
      2. Where risk of immediate suicide is high, and 
      3. Where comorbid general medical conditions preclude the safe use of antidepressants.
         
  2. USE WITH SPECIFIC DISORDERS
    1. Persistent Depressive Disorder (Dysthymia) 
      1. Antidepressants may be tried for initial treatment in individuals with Persistent Depressive Disorder (Dysthymia).
      2. Antidepressants may be tried with individuals who have not successfully responded to six (6) months of treatment with psychotherapy alone or psychotherapy and other psychopharmacologic agents.
    2. Substance/Medication-Induced Disorders with Mood Symptoms
      1. Antidepressant medications may be tried when detoxification from the responsible substance alone does not adequately resolve symptomatology or is not possible.
    3. Disorders with Mood Symptoms Due to Another Medical Condition
      1. Antidepressant medications may be tried when treatment of the responsible general medical condition alone does not adequately resolve symptomatology or is not possible.
    4. Antidepressant medications may be used for other disorders characterized by mood or affect disturbances only with appropriate additional justification in the medical record.
    5. SSRIs should be tried for the treatment of Bulimia Nervosa.
    6. Bupropion and SNRIs may be used to treat Attention Deficit Hyperactivity Disorder (ADHD) when psychostimulant medications, guanfacine, clonidine, and atomoxetine are ineffective, contraindicated, or unavailable.
    7. SSRIs may be used for Obsessive-Compulsive and related disorders such as Trichotillomania and Body Dysmorphic Disorder.
    8. SSRIs/SNRIs should be tried initially for the treatment of Major Depressive Disorder when no contraindications exist for their use.
    9. Antidepressant medication should be given with concurrent mood-stabilizing medication for the treatment of Bipolar Disorder, depressive episode.
      1. Antidepressant medication should not be given on a long-term basis to individuals with bipolar disorders as it may induce rapid cycling.
         
  3. MULTIPLE MEDICATIONS
    1. Adjunctive
      1. When a second antidepressant is also poorly tolerated or ineffective after an adequate clinical trial, further trials with other antidepressants or augmentation strategies should be tried.
      2. When psychotic symptoms are present, antipsychotic medications may be used in conjunction with antidepressant medications for the treatment of depressive episodes during:
        1. Major Depressive Disorders,
        2. Bipolar Disorders,
        3. Substance/Medication-Induced Disorders with Mood Symptoms, and
        4. Disorders with Mood Symptoms Due to Another Medical Condition
      4. Mood stabilizing medications should, in general, be used in conjunction with antidepressant medications when treating depressive symptoms in bipolar disorders to minimize the likelihood of a manic episode.
      5. Antidepressants should be used only during depressive episodes in bipolar I disorder, as longer-term use is associated with an increased risk of manic episodes.
      6. Selected antipsychotic medications, lithium or triodiothrianine may be used during depressive episodes to augment the therapeutic response to antidepressant medication when antidepressant medications alone are not effective.
      7. Dosage schedules should be adjusted based on age and the presence of general medical conditions.
    2. Concurrent
      1. Only one antidepressant medication should generally be used in most circumstances, but two (2) may be used concurrently in exceptional circumstances, for example:
        1. When trazodone is initially used to treat sleep disturbance in an individual whose depressive episode is likely to respond to a less sedating antidepressant;
        2. When bupropion is used to ameliorate sexual side effects from SSRIs;
        3. When one antidepressant is being tapered while another is being initiated; or
        4. When a patient fails to respond to numerous trials of monotherapy from multiple antidepressant classes.
           
  4. DOSAGES
    1. Antidepressant medications should be continued for 6 to 12 months in treatment-responsive individuals with a diagnosis of major depressive disorder, single episode, in partial or complete remission, after which time a gradual taper should be tried.
    2. Antidepressant medications may be continued for an indefinite period in treatment-responsive individuals with a diagnosis of major depressive disorders, recurrent, in partial or complete remission.
      1. Decisions regarding indefinite treatment should be informed by client preference and the past course of the illness.
    3. Dosage schedules of antidepressant medications should be determined by clinical situation and, with nortriptyline, imipramine, and desipramine, laboratory monitoring of medication blood levels as necessary.
    4. Trials of antidepressant medications should be at dosages generally recognized as effective unless untoward effects prevent this.
      1. In such cases, the individual should be switched to a different antidepressant medication.
         
  5. LABORATORY MONITORING
    1. Laboratory monitoring of individuals taking antidepressant medications should be determined by clinical situation, including:
      1. Type of medication,
      2. Health risk factors,
      3. Duration of treatment,
      4. Concurrent general medical condition, and
      5. Concurrent medications,
    2. Laboratory monitoring of individuals taking antidepressant medications should be consistent with DMH Parameter 3.7 General Health-Related Monitoring and Interventions in Adults.
    3. A baseline electrocardiogram (EKG) should be obtained prior to treatment with tricyclic antidepressants in individuals with cardiac disease or who are over age 55.
       
  6. ADDITIONAL PRECAUTIONS
    1. Precautions
      1. Special care must be taken to avoid serotonin syndrome by allowing 2 weeks between the termination of an MAOI and initiation of a non-tricyclic medication.
      2. No more than a 14-day supply of antidepressant medication should be provided when they are prescribed for individuals at significant risk for deliberate overdose.
      3. For pregnant women who have major depression, an antidepressant prescription should be accompanied by:
        1. Documentation in the medical record of attempted notification to the primary care provider or obstetrician/gynecologist;
        2. Informed consent; and
        3. Discussion of the risks/benefits of using a specific antidepressant.
    2. Contraindications
      1. Nefazodone should not be used in any but the most exceptional cases, as the risks of hepatotoxicity generally outweigh any potential therapeutic benefits relative to other antidepressants.
    3. Black Box Warning
      1. The FDA “Black Box Warning” regarding suicidal behavior, as follows and currently attached to all antidepressants, should be carefully reviewed:
        1. “Suicidality in Children and Adolescents Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. [Drug Name] is not approved for use in pediatric patients except for patients with [Any approved pediatric claims here]. (See Warnings and Precautions: Pediatric Use)Pooled analyses of short-term (4 to 16 weeks) placebo-controlled trials of nine antidepressant drugs (SSRIs and others) in children and adolescents with MDD, obsessive-compulsive disorder (OCD), or other psychiatric disorders (a total of 24 trials involving over 4400 patients) have revealed a greater risk of adverse events representing suicidal thinking or behavior (suicidality) during the first few months of treatment in those receiving antidepressants. The average risk of such events on the drug was 4%, twice the placebo risk of 2%. No suicides occurred in these trials."
      2. Individuals started on antidepressants should be specifically cautioned to immediately report any emergent suicidal ideation or intent to the prescribing or furnishing clinician.
      3. Individuals for whom antidepressants are prescribed should be regularly questioned about the presence of dysphoria, restlessness, and emergent suicidal ideation and behavior. 
        1. Responses should be documented.
      4. Individuals with emergent suicidal ideation or behavior who have recently started on SSRIs should be immediately changed to another non-SSRI antidepressant medication.