The “My Psych Board” Customer Service promise for all our customers

When looking at new brands in our personal lives, one of the FIRST things we look for are brands with strong customer service.

If you can find a brand that puts you first, you know that no matter what, you’ll get double the value out of whatever they’re selling, sharing, telling you, and so on.

Since the creation of “My Psych Board” and the “Westlake Brain Health Clinic”; we’ve understood deep within our core we wanted to provide top-notch customer service. Customer service that would truly remain unmatched by any other brands within our space… and it has!

When individuals interact with us they aren’t just another number, they’re a personality!

Within our customer service, we strive to provide you with the tools necessary to overcome any of your questions and obstacles that may get in your way. From general information, tutor calls, and just being someone to talk you through the challenging times of taking your board exams; we’re here for you!

This is our pledge to you.

Other brands focus more on growth of their own personal brands while our focus is YOU! Besdies, if some of these brands have been around for 15+ years… shouldn’t they be at our level of customer service, products, knoweldge, and overall quality of services? 

Yes. Yes They Should. 

But they arent…

So next time you have questions, concerns, or just want some expert guidance to reach out and we’re here 24/7. Whether it’s a DM, Email, Phone Call, or Comment, just know, we can’t wait to speak to you!

Ready to dive in? 

Utilize our expert-curated Question Banks and maximize your studying today!

Need more guidance?

Contact us today! We’ll help YOU pass your Boards with ease!

Introducing: Observership Programs powered by My Psych Board

I bet you didn’t know we offered Observership programs right here at My Psych Board!

Yes, that’s right… we are your one-stop-shop place for all your studying needs, prep, and learning (and that’s not going to change)… We’re much more than your average Board Exam prep Q-Banks. But wait, we have much more to offer you. 

We can help get YOU into an Observership program which is an essential part of your career journey.

So what is an Observership & Why do residents need this?

Imagine an Observership as a Medical Internship that can be done both in person and via Telehealth to give residents practical, hands-on experience.

As part of this experience, you will be required to watch and listen to patient histories, physical examinations, procedures, surgeries, outpatient appointments, teaching rounds, and educational conferences. The entire experience is generally longer than a day, but no longer than 4 weeks!

The importance of this can not be overlooked. 

Most students will need to cover Observership hours to complete their residency.

Now of course this may not be required in your field so if you’re unsure if you need this (or just want to be safe) just send us a DM via our Instagram (@MyPsychBoard), Email, or drop us a call so we can point YOU in the right direction.

Ready to get started? Contact us today! We can’t wait to travel with you along your journey to passing your Psychiatric Board Exams!

Studying Tips Broken Down: Set yourself up for success!

Time to get back to studying… wow… it seems like just yesterday the summer was just kicking off!

Now it’s time to head back to school, so naturally, we’ve received some DMs asking “How can I make the most of the upcoming school year?”.

Going back to school can seem like an overwhelming time and it can be, but we’ve put together a few studying tips that should help you excel in your learning.

Our Top Five Tips!

1️⃣ Get Organized…

Get all your study materials together, ensure you know your new schedule, and plan your time properly. Take a look at each class; What do you need? What do you already have?

2️⃣ Be Active In Your Learning.

Don’t just follow your current curriculum. Seek out other experiences and knowledge whether you’re in a group studying, participating in volunteer labs/programs/research groups, and much more. You can gain more knowledge and experience this way!

3️⃣ Study, Study, Study — but with others!

Studying with others can improve your memory recall, provide other points of view, and give you a great trusted group whom you can make memories with outside of just staying. Since you’re all going through the same experiences together it can help ease the stress. You could even utilize various question banks and tools to make the most of the study sessions!

4️⃣ Use Your Time Wisely

Just because others are going out every night doesn’t mean you need to… you can still have a solid social life AND go to school. Write down and prioritize everything you need to do. Ensure you have built a solid routine, and get what you need to do, but also make sure you are taking time to have fun too (which brings us to our next section.)

5️⃣ Take Care Of Your Mental Health!!!

This is last but certainly NOT least. We’ve said it before and we will keep saying it. Take care of yourself and your mental health. You need to ensure you aren’t pushing yourself too far. Find things and activities which help you relax. School is not forever so take everything one step at a time. Use your support group/study group we mentioned in point 3.

Need some additional tips or a tutor? Contact us today!

Who is My Psych Board?

My Psych Board is a board review website created by Dr. Abdel, MD, MBB. CH., founder and CEO of Westlake Brain Health clinic in Cleveland, OH. This program offers access to unique courses and question banks to prepare residents and medical students for the American Board of Psychiatry and Neurology (ABPN) Psychiatry Certification Exam, Psychiatry Resident In-Training Examination, United States Medical Licensing board examination, and Nurse Practitioner examination. Each question bank is specifically tailored to the required difficulty and type of questions expected for the different board exams. New questions are continually being added to the question banks, ensuring the most current and up-to-date information is being made available.

My Psych Board is created by experts in the field and covers all the topics you need to master in order to pass your board-certifying exams. Feedback is given immediately in Practice Mode as questions are answered, including in-depth explanations that accompany each question for both correct and incorrect answer options. Additionally, students have the option of accessing a one-time phone call with Dr. Abdel to discuss their best studying strategies and one-on-one tutoring to help them gain maximum preparation. My Psych Board is customer oriented; we take your feedback seriously and are always looking for ways to improve the user experience! 

How can our study resources help YOU pass your board exams? Let us explain!

Have you ever used a company that books flights, cars, and hotels, and provides travel information? It’s perfect because you get everything you need all in one place, and it takes the stress out of traveling.

Hmm…Sounds familiar? That’s because we do the same… but for your Board Exams!

We are your one-stop website to help you learn, study, and easily pass your boards in your free time.

So why do you need to go anywhere else when everything is covered here? We offer: 

  • Free Trials
  • Niche-specific question banks
  • Expert assistance 
  • Up-to-date content
  • Telehealth observership/preceptorship programs (with an offered DISCOUNT on question banks!)

Whether it’s a q-bank trial, blog content, free helpful videos, or anything else you may need…Choose My Psych Board each time.

Our only goal is to see you succeed!

Access our question banks here to get started with a FREE trial (with No CC Required!) — Still, feeling unsure about your studies? Contact us and we can help YOU pass your boards with ease!

Who is My Psych Board?

Prepare to pass your board exams with ease! My Psych Board offers access to four question banks, each uniquely tailored to the studying needs of those preparing to take the ABPN Certification Examination, PRITE Examination, USMLE – Psychiatry and Neurology categories, and Nurse Practitioner Examination.

Within our customer service, we strive to provide you with the tools necessary to overcome any of your questions and obstacles that may get in your way. From general information, tutor calls, and just being someone to talk you through the challenging times of taking your board exams; we’re here for you!

Navigating the Nurse Practitioner Exam: A Quick Breakdown

NAVAGATING THE Nurse  Practitioner Exam A Quick Breakdown!

Ready to learn more about the PMHNP-BC Exam?

We’re going to dive into what this exam looks like and give you the information you need to pass it with ease!

EXAM FORMAT

Timeframe and Questions: 

You have 4 hours to complete the exam which consists of 25 pretest and 150 exam questions

Scoring: 

There’s no penalty for incorrect answers, so if you’re unsure of an answer it’s better to just take a guess and fill in the blank!

Results: 

You get the result immediately after taking the test. No waiting!

EXAM CONTENT

Psychotherapies and Related theories:

This makes up 15% of the total score with 22 questions

Ethical and Legal Principals.

This makes up 15% of the total score with 23 questions

Scientific Foundations:

This makes up 20% of the total score with 30 questions

Diagnosis and Treatment:

This makes up 25% of the total score with 37 questions

Advanced Practice skills. This makes up 25% of the total score with 38 questions

EXAM COSTS

Initial Application Fee:

$350 (U.S. students)/ $750 (International students)

Actual Exam Fees

Non-members:

$395

ANA members:

$295

American Association of Nurse Practitioners Student member: 

$290

EXAM DAY

  • Arrive at least 15 minutes early
  • Bring a valid photo ID
  • You may NOT bring any personal items into the Test Center, including cell phones or water bottles
  • You will be given time to familiarize yourself with the computer system prior to the exam starts

Want to see what the question are REALLY like? 

We offer a FREE trial! Just head over to our website (exams.mypsychboard.com) to get started today risk-free (with no Credit Card required!)

Feeling like you need a bit of extra help? Contact us OR sign up for our tutoring!

Taking Your Psychiatric Board Exams: The real costs broken down

Taking Your Psychiatric Board Exams- The real costs broken down

We are commonly asked this key question about exams, 

“How much does it cost for this or that, or this…”

Aside from your sanity…here is a compilation of all of the costs clearly stated just for you! Learn about your niche-specific costs for the ABPN Certification Examination, PRITE Examination, USMLE – Psychiatry and Neurology categories, and Nurse Practitioner Examination.⁠ ⁠⁠

Let’s jump into it!

ABPN Exam

ABPN Initial certification fees: 

$1,945

Annual Fees:

(1) certification $175

(2) certifications $240

(3) certifications $310 ⁠ 

USMLE Exam

USMLE Application fee: 

$150

Step 1 & Step 2 CK:

$975 (per each exam)

Rescheduling fee:

$0-$600 

(dependent on the Exam and date of cancellation)

Extension of Eligibility Period:

$90/exam

PRITE Exam

Child PRITE:

$125

Regular PRITE:

$140

Nurse Practitioner Exam

Application fees: 

United States $350

International Students $750

Non-member: $395

ANA (American Nurse Association) member:

$295

American Association of Nurse Practitioners Student member:

$290

Re-examination fee:

$250

Want to start your week off with a good deed? 

Share this with your friends/classmates. It will help ease their stress so they can spend less time searching the web and more time …WITH YOU.⁠ ⁠

Now that you’ve gotten the costs straight… it’s time to study study study!

Did you know we offer a FREE trial for our question banks? Just head over to our website (exams.mypsychboard.com) to get started today risk-free (with no Credit Card required!)

Feeling like you need a bit of extra help?

Contact us OR sign up for our tutoring!

Failed Your Psychiatric Board Exams? What should you do now?

Failed Your Psychiatric Board Exams? What should you do now?

So let’s say you’ve taken round one and failed… what now?⁠

Firstly, it’s ok! You’re human, breathe. Take a break and avoid freaking out. Take a moment to step away and have some much-needed “you time”. You’ll want to clear your head and get a new perspective, if you need a week or more…take it!

Now that you’ve taken time for yourself, it’s time to jump back in. Create a realistic timeline and schedule that will work for you. Cover the big areas and focus on where you were unsure.⁠

Don’t be afraid to change your studying routine. Ask yourself — Are there issues with your previous method? Do you have all the right/up-to-date resources? Are you staying away from distractions?⁠

Finally, when you’re going back in keep it focused on the questions and stay out of your head. We know it’s easier said than done but everyone goes through ups and downs. Check out our post on what to do differently when retaking the boards for more inspiration!

You may learn something from this experience!

Did you know we offer a FREE trial for our question banks? Just head over to our website (exams.mypsychboard.com) to get started today risk-free (with no Credit Card required!)

Feeling like you need a bit of extra help?

Contact us OR sign up for our tutoring!

Our Top Tips: How to Survive Your Psychiatric Residency!

Our Top Tips - How to Survive Your Psychiatric Residency!

Ok, hear us out for a minute…⁠ Surviving your residency is easier than you think.⁠ ⁠ 

YES, of course, that’s a loaded statement… NO, we aren’t saying it’s not incredibly challenging (because it is…) but we promise you’re overthinking it. You CAN do this. You may have heard horror stories or that it was the worst moment of someone’s life but let’s be real. 

It shouldn’t be.⁠

 Thousands before you have done it and thousands after you will do it too.

How you handle it makes all the difference in what you’ll get out of your residency.⁠ Here are 5 TIPS on how to survive:

#1 HAVE A POSITIVE MINDSET…

Before you begin anything, you should always go in with the correct mindset. If you think things are going to be horrible…then they will be! But if you go in understanding that there will be both highs and lows, you’ll be better prepared to face them.

#2 HAVE A GREAT SUPPORT SYSTEM…

This goes with most things in life. The company you keep will help get you through hard moments. That’s what friends are for. But this support system should also be those around you too! Other residents know what you’re going through, so be sure to include them. It helps so much! ⁠

#3 DON’T NEGLECT YOUR MENTAL AND PHYSICAL HEALTH…

We’ve said this before and we’ll say it again: Take care of your mind AND body! Don’t bottle things up, talk to your support system, and get further help if you need it. It’s a challenging time. Outside of this, being active works WONDERS. Your body will thank you.

#4 IT’S OK TO SAY “I DON’T KNOW” (DO IT MORE!)…

You don’t know everything (that’s why you’re here). Don’t be a “know it all”, it can come back to hurt you. If you’re asked something and you’re really unsure, say that! Saying I don’t know will help you get the answers you need. Don’t feel silly. You’re learning!

#5 IT GETS BETTER…

It will get better!!! The start can be overwhelming and a lot to take in, but use that support system. Once you get in the groove, you’ll start to feel much more relaxed. Give it time. It’s long, draining, and emotional but there are perks. They may not last long but the amount of information and experiences you’ll take away from it, in the end, is all worth it. 

You got this, you can survive… you can thrive! ⁠

Still, feeling overwhelmed?

Contact us and let’s talk through it together.

Q&A: Pharmaceutical Specifications, Treatment Resistant Depression, and Intervention

PHARMACEUTICAL SPECIFICATIONS FOR DEPRESSION

Will SSRI and SNRI side effects go away with time?

SRIs and SNRIs are safer and better tolerated than other classes of antidepressants. Side effects are typically mild and they often go away after using the medication for a few days. Common side effects during the initiation of treatment that typically go away with time include gastrointestinal disturbance, headache, decreased appetite, and initial weight loss. Symptoms that sometimes go away with time include insomnia, vivid dreams, and emotional blunting. Other symptoms, if present, are likely to not resolve on their own which include sexual dysfunction (decreased libido or arousal, anorgasmia, and delayed ejaculation in men), restlessness/akasthisia, and weight gain. There is no consistent weight gain in short-term RCTs (4-12 weeks), but retrospective cohorts indicate they may cause modest gains of up to 1kg on average after 1 year.

What antidepressants are safe in liver disease?

Antidepressant drugs can cause drug-induced liver injury. Although data on antidepressant-induced liver injury are scarce, 0.5%−3% of patients treated with antidepressants may develop asymptomatic mild elevation of serum aminotransferase levels. All antidepressants can induce hepatotoxicity, especially in elderly patients and those with polypharmacy. Liver damage is in most cases idiosyncratic and unpredictable, and it is generally unrelated to drug dosage. The antidepressants associated with greater risks of hepatotoxicity are iproniazid, nefazodone, phenelzine, imipramine, amitriptyline, duloxetine, bupropion, trazodone, tianeptine, and agomelatine. The antidepressants that seem to have the least potential for hepatotoxicity are citalopram, escitalopram, paroxetine, and fluvoxamine.

What antidepressants are safe in kidney disease?

Comorbidity rates of depression in patients with renal disease are high, making the use of antidepressants in renal disease common. SSRIs are generally preferred in this population and medications should be started a low doses and titrated slowly. Among the SNRIs venlafaxine may be used, however the require dose adjustments and duloxetine should be avoided in severe renal impairment. Bupropion should be avoided in patients with chronic renal failure and on dialysis since the active metabolite (hydroxybupropion) is not dialyzable and plasma levels are increased in patients with even mild renal impairment thus increasing the risk for seizures and other adverse side effects. TCAs should be decreased by 50% in geriatric patients with moderate to severe renal dysfunction.

What other conditions are antidepressants used for?

The use of antidepressant medications are not limited to depressive disorders. There is evidence for a variety of indications. Some of these include:

  • Obsessive compulsive disorder: SSRIs (in high doses), TCAs (clomipramine)
  • Panic disorder: SSRIs, TCAs, MAOIs
  • Eating disorders: SSRIs (in high doses), TCAs
  • Social anxiety disorder (social phobia): SSRIs, SNRIs, MAOIs
  • Generalized anxiety disorder: SSRIs, SNRIs (venlafaxine), TCAs
  • Posttraumatic stress disorder: SSRIs
  • Irritable bowel syndrome: SSRIs, TCAs
  • Enuresis: TCAs (imipramine)
  • Neuropathic pain: TCAs (amitriptyline and nortriptyline), SNRIs
  • Chronic pain: SNRIs, TCAs
  • Fibromyalgia: SNRIs
  • Migraine headaches: TCAs (amitriptyline)
  • Smoking cessation: Bupropion
  • Premenstrual dysphoric disorder: SSRIs
  • Insomnia: Mirtazapine, trazodone, TCAs (doxepin)

TREATMENT RESISTANT DEPRESSION

What is the definition of treatment-resistant depression?

Treatment-resistant depression (TRD) is most commonly defined as a failure of treatment response or remission with two or more treatment attempts of adequate dose and duration. Unfortunately, there is not a clear consensus about this definition. Specifically, what is an adequate response? 50% reduction in symptoms? Complete resolution of symptoms? Also, what are the specifics regarding the adequacy of both dose and duration of treatment? 

While not a consensus, the most commonly used definition in research studies regarding response are the following :

  • No response: Improvement <25 percent.
  • Partial response: Improvement 25 to 49 percent.
  • Response: Improvement ≥50 percent but less than the threshold for remission.
  • Remission: Rating scale scores within the normal range.

What are augmentation options if antidepressant medications fail to show an adequate response?

Some patients may not achieve an adequate treatment response after a full trial of SSRI or SNRI at therapeutic doses. If there is no response then switching to another medication in the same class or a different class should be considered. If there is some response than maximizing dose or augmentation strategies should be considered. There are a number of medications that have been trialed for treatment resistant depression. We will list some of the more common augmentation strategies below:

  • Buproprion: included in the STAR*D trial and typically well-tolerated from a side effect perspective. Can also help with SSRI induced sexual side effects, smoking cessation, and weight loss.
  • Mirtazapine: effective antidepressant and improves appetite and sleep. Be aware of weight gain and sedation.
  • Lithium: well supported in the literature and is recommended by the NICE guidelines.
  • Second-generation antipsychotics (SGAs): particularly aripiprazole, quetiapine, olanzapine, and risperidone (2nd choice) have shown to be effective.
  • Buspirone: supported by STAR*D trial. High doses are usually required and poorly tolerated due to dizziness at high doses.
  • Lamotrigine: reasonably well researched and possibly the best tolerated augmentation strategy. Appropriate dosing is unclear and requires slow titration due to risk of Steven Johnson’s Syndrome.
  • T3 (Triiodothyronine): augmentation has some research support but also has negative studies.
  • TCAs or MAOIs can be used as augmentation or to replace the primary antidepressant (SSRI/SNRI). Often considered later in the treatment algorithm due to significant side effects, food restrictions, and higher lethality in overdose.

INTERVENTION TECHNIQUES FOR TREATMENT RESISTANT DEPRESSION

What interventional techniques are available for treatment resistant depression?

Electroconvulsive Therapy (ECT)

  • Formerly known as shock therapy.
  • Involves a brief electrical stimulation (generalized seizure) of the brain while the patient is under general anesthesia.
  • Most effective and rapid treatment in severe depression, psychotic depression, depression with catatonia, and treatment refractory depression.
  • There are no absolute contraindications to ECT, however several relative contraindications exist including recent myocardial infarction or stroke, increased intracranial pressure, retinal detachment, and unstable dentition.
  • Standard practice in the U.S. is to give treatments three times per week.
  • Most symptoms improve substantially in 6-12 treatments, however there is no absolute standard number of treatments.
  • Certain medications that affect the seizure threshold should be held prior to ECT including benzodiazepines, valproate, lamotrigine, gabapentin, carbamezapine, and lithium.
  • ECT can cause acute confusion, anterograde and retrograde amnesia. These are typically the most feared side effects from patients. Many patients do experience some adverse cognitive effects, however objecting indicates that impairment is generally short lived (weeks). ECT does not appear to be associated with an increased risk of dementia.

Transcranial Magnetic Stimulation (TMS)

  • Machine that produces weak repetitive electric currents in the brain tissue by rapidly changing magnetic fields.
  • Numerous small-scale studies have demonstrated efficacy in the treatment of major depression; however, studies show less efficacy than for ECT.
  • TMS works by passing a weak alternating electrical current through a metal coil placed against the scalp. This produces rapidly changing magnetic fields. These magnetic signals pass through the skull and induce electric currents that depolarize neurons in a specific area of the surface of the cortex and associated neural circuits. The mechanism of antidepressant effects is not completely understood.
  • FDA approved for major depressive disorder, migraine headaches, and obsessive-compulsive disorder. There is also growing evidence for anxiety disorders and PTSD.
  • Treatment typically occurs every weekday for 4 to 6 six weeks or a total of 20-30 treatments. Each session lasts around 30-40 minutes.
  • Relative contraindications of TMS include implanted metallic hardware or electrical devices and unstable general medical disorders. Patients with epilepsy or increased risks of seizures can be considered for low frequency TMS if benefits outweigh the risks.

Intranasal Ketamine

  • Ketamine is technically considered a dissociative anesthetic, however has been discovered to be helpful in treatment resistant depression. It is an NMDA glutamate antagonist and also affects brain growth factors and opioid receptors, suggesting a possible mechanism for its antidepressant properties.
  • Unlike many of our treatment options (antidepressant medications, psychotherapy, TMS) esketamine nasal spray has the unique benefit of a rapid onset of action to reduce suicidality or other serious acute symptoms of depression.
  • The recommended frequency of intranasal esketamine for acute suicidal ideation or behavior in adults with unipolar major depression is twice weekly for four weeks. After four weeks of treatment with esketamine, its benefit should be evaluated to determine the need for ongoing treatment.
  • Side effects may include increased blood pressure, perceptual disturbances, or dissociative / out of body experiences.

Vagus Nerve Stimulation (VNS)

  • Surgical treatment involving the implantation of a medical device that sends electrical impulses to the brain via the vagus nerve.
  • Has been used for epilepsy since 1997 and for refractory major depression since 2005.

Deep Brain Stimulation (DBS)

  • Surgical treatment involving the implantation of a medical device that sends electrical impulses to specific parts of the brain.
  • Originally used in treatment refractory neurologic conditions such as Parkinson’s disease, dystonia, and tremor.
  • Now used in treatment refractory major depression.

REFERENCES

1. Hasin DS, Sarvet AL, Meyers JL, et al. Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers in the United States. JAMA Psychiatry. 2018;75(4):336–346. doi:10.1001/jamapsychiatry.2017.4602

2. National Institute for Health and Care Excellence. (2009). Depression in adults: recognition and management. Retrieved from https://www.nice.org.uk/guidance/cg90/chapter/Recommendations

3. Cuijpers, P., Andersson, G., Donker, T., & van Straten, A. (2011). Psychological treatment of depression: results of a series of meta-analyses. Nordic journal of psychiatry, 65(6), 354–364. https://doi.org/10.3109/08039488.2011.596570

4. Blumenthal SR, Castro VM, Clements CC, et al. An Electronic Health Records Study of Long-Term Weight Gain Following Antidepressant Use. JAMA Psychiatry. 2014;71(8):889–896. doi:10.1001/jamapsychiatry.2014.414

5. Voican, C. S., Corruble, E., Naveau., and Perlemuter, G. (2014). Antidepressant-Induced Liver Injury: A Review for Clinicians. The American Journal of Psychiatry. https://doi.org/10.1176/appi.ajp.2013.13050709

6. Ward, S. W., Reach, W. J., &amp; Thomas, C. (2016). When to adjust the dosing of psychotropics in patients with renal impairment. Current Psychiatry, 15(8), 60–66.

7. Puckett, J. A., Beach, S. R., &amp; Taylor, J. B. (2020). Pocket psychiatry. Wolters Kluwer.

8. Gaynes BN, Asher G, Gartlehner G, Hoffman V, Green J, Boland J, Lux L, Weber RP, Randolph C, Bann C, Coker-Schwimmer E, Viswanathan M, Lohr KN. Definition of Treatment-Resistant Depression in the Medicare Population. Technology Assessment Program. Project ID: PSYT0816. (Prepared by RTI–UNC Evidence-Based Practice Center under Contract No. HHSA290201500011I_HHSA29032006T). Rockville, MD: Agency for Healthcare Research and Quality. February 2018. http://www.ahrq.gov/clinic/epcix.htm.

9. Taylor, D., Barnes, T. R. E., Young, A. H. (2018). Depression. The Maudsley Prescribing Guidelines in Psychiatry (13th ed., pp. 208–212). Wiley Blackwell.

10. Williams, N. R., Taylor, J. J., Kerns, S., Short, E. B., Kantor, E. M., & George, M. S. (2014). Interventional psychiatry: why now?. The Journal of clinical psychiatry, 75(8), 895–897. https://doi.org/10.4088/JCP.13l08745

11. United States Food and Drug Administration approved labelling. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/211243s004lbl.pdf (Accessed on August 10, 2020).

Syndrome Snapshot: Depression and Treatment Options

What is depression?

Everyone experiences a range of emotions that typically vary based on events and circumstances. Normally feelings of disappointment, sadness, and grief ebb and flow. By contrast, depression tends to feel heavy and constant. People who are depressed are less likely to be feel happy, have good days, be cheered, comforted, or consoled. Clinically, a major depressive episode is characterized by at least two weeks of depressed mood or a loss of interest in enjoyable activities. It also includes a number of other symptoms which may include difficulties with sleep, feelings of worthlessness or guilt, fatigue, difficulty concentrating, appetite changes, or recurrent thoughts of death or suicide.

Depression and Suicide

According to the Centers for Disease Control and Prevention (CDC) in 2018, suicide was the 10th leading cause of death overall in the United States, claiming the lives of over 48,000 people. It is the 14th leading cause of death globally. Individuals dealing with depression are at a higher risk of suicide than other individuals. Some studies estimate this risk to be 20-30 times higher than the non-depressed population. Other risk factors for suicide include past history of suicide attempt, history of self-directed violence, family history of suicide, having a psychiatric disorder, lack of social supports, history of childhood abuse, substance use, homelessness, access to firearms, and more.

Depression and Bereavement

Grief or bereavement is the powerful emotional response that occurs following the death of a loved one or other difficult losses in life. Stages of bereavement may include denial and isolation, anger, bargaining, sadness, and acceptance. The majority of survivors heal over time and their symptoms of grief gradually improve as they resume their routines and activities. They are able to function in their life. Complicated grief occurs when grief responses are considered excessive and depression may occur if individuals do not progress through the normal healing process and have continued symptoms and dysfunction and prolonged feelings of sadness and hopelessness.

First Line Treatments

Mild: Active monitoring, individual guided self‐help, exercise, cognitive behavioral therapy (CBT), or other psychotherapy protocols are preferred.2 Antidepressant medications are not recommended as a first‐line treatment in recent‐onset mild depression.

Moderate to severe: Antidepressants are recommended for the treatment of moderate to severe depression and for dysthymia (persistent depressive disorder).

Psychotherapy

Multiple meta-analyses show psychological therapies to be as effective as antidepressant medications for those with mild or moderate severity of depression. Studies also demonstrate the effectiveness of a number of different types of therapy in depression3. Effective therapies include:

•Cognitive behavior therapy (CBT): based on the idea that our thoughts (cognitions), behaviors, and emotions are all interrelated, so that if we change one then we change the rest.

Interpersonal psychotherapy (IPT): intervention that focuses on relieving symptoms by improving interpersonal functioning. A central idea in IPT is that psychological symptoms can be understood as a response to current difficulties in everyday relationships with other people.

•Psychodynamic psychotherapy: the psychological interpretation of mental and emotional processes. Rooted in traditional psychoanalysis, it draws from object relations, ego psychology, and self psychology. It was developed as a simpler, less-lengthy alternative to psychoanalysis.

•Problem-solving therapy (PST): brief intervention patients experiencing depression and distress related to inefficient problem-solving skills. The PST model instructs patients on problem identification, efficient problem-solving, and managing associated depressive symptoms.

Non-directive supportive therapy: relies on the therapeutic alliance to alleviate symptoms, improve self-esteem, restore relation to reality, regulate impulses and negative thinking, and reinforce the ability to cope with life stressors and challenges.

•Behavioral activation therapy: behavioral activation is a component of CBT but behavioral strategies can also be used alone. Behavioral activation is based on the theory that, as individuals become depressed, they tend to engage in increasing avoidance and isolation, which serves to maintain or worsen their symptoms

Pharmaceuticals

There are a number of available antidepressant classes that have evidence for the treatment of depression, anxiety, and other disorders. Each class of antidepressants have a unique mechanism but they all act to manipulate the levels of neurotransmitters in the brain that are responsible for modulating mood and emotions. Examples include serotonin, norepinephrine, and dopamine. Classes of antidepressants include: Selective serotonin reuptake inhibitors (SSRIs); Serotonin-norepinephrine reuptake inhibitors (SNRIs); Tricyclic antidepressants (TCAs) and Tetracyclic antidepressants; Monoamine oxidase inhibitors (MAOIs); and novel or atypical antidepressants.

All antidepressant classes have similar treatment response rates in treating major depression but vary in their mechanism of action, safety, and side effect profiles. SSRIs and SNRIs are the most commonly prescribed antidepressants and are considered first-line treatment due to several distinct advantages:

  • Low side effect profile, most of which resolve with time
  • No food restrictions (unlike MAOIs)
  • Much safer in overdose (unlike TCAs and MAOIs)

Practice Question:

A 47-year-old patient comes in discussing feelings of tiredness, decreased appetite, intense periods of irritation, lack of enjoyment in activities they once enjoyed, interpersonal relationship issues, and suicidal ideation. Which FDA-approved pharmaceutical treatment is the first-line treatment for a patient experiencing these symptoms?

A Escitalopram

B Risperidone

C Clozapine

D Fluvoxamine

E Imipramine

Answer: A

Explanation: In older adults suffering from depression, the first line of treatment are SSRIs, such as escitalopram (choice A). Fluvoxamine (choice D) is an SSRI that is only approved for OCD. If the patient had come forward with symptoms for schizophrenia, then an antipsychotic medication, such as clozapine (choice C), would be a good medication to consider prescribing. Risperdal (choice B) is an antipsychotic that is more useful in cases of aggression. Other antidepressants, such as monoamine oxidase inhibitors and tricyclic medications (choice E), are very effective in treating depressive disorders, but these medications are not amongst the group of medications that should be used as a first-line treatment option.

REFERENCES

1. Hasin DS, Sarvet AL, Meyers JL, et al. Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers in the United States. JAMA Psychiatry. 2018;75(4):336–346. doi:10.1001/jamapsychiatry.2017.4602

2. National Institute for Health and Care Excellence. (2009). Depression in adults: recognition and management. Retrieved from https://www.nice.org.uk/guidance/cg90/chapter/Recommendations

3. Cuijpers, P., Andersson, G., Donker, T., & van Straten, A. (2011). Psychological treatment of depression: results of a series of meta-analyses. Nordic journal of psychiatry, 65(6), 354–364. https://doi.org/10.3109/08039488.2011.596570

4. Blumenthal SR, Castro VM, Clements CC, et al. An Electronic Health Records Study of Long-Term Weight Gain Following Antidepressant Use. JAMA Psychiatry. 2014;71(8):889–896. doi:10.1001/jamapsychiatry.2014.414

5. Voican, C. S., Corruble, E., Naveau., and Perlemuter, G. (2014). Antidepressant-Induced Liver Injury: A Review for Clinicians. The American Journal of Psychiatry. https://doi.org/10.1176/appi.ajp.2013.13050709

6. Ward, S. W., Reach, W. J., &amp; Thomas, C. (2016). When to adjust the dosing of psychotropics in patients with renal impairment. Current Psychiatry, 15(8), 60–66.

7. Puckett, J. A., Beach, S. R., &amp; Taylor, J. B. (2020). Pocket psychiatry. Wolters Kluwer.

8. Gaynes BN, Asher G, Gartlehner G, Hoffman V, Green J, Boland J, Lux L, Weber RP, Randolph C, Bann C, Coker-Schwimmer E, Viswanathan M, Lohr KN. Definition of Treatment-Resistant Depression in the Medicare Population. Technology Assessment Program. Project ID: PSYT0816. (Prepared by RTI–UNC Evidence-Based Practice Center under Contract No. HHSA290201500011I_HHSA29032006T). Rockville, MD: Agency for Healthcare Research and Quality. February 2018. http://www.ahrq.gov/clinic/epcix.htm.

9. Taylor, D., Barnes, T. R. E., Young, A. H. (2018). Depression. The Maudsley Prescribing Guidelines in Psychiatry (13th ed., pp. 208–212). Wiley Blackwell.

10. Williams, N. R., Taylor, J. J., Kerns, S., Short, E. B., Kantor, E. M., & George, M. S. (2014). Interventional psychiatry: why now?. The Journal of clinical psychiatry, 75(8), 895–897. https://doi.org/10.4088/JCP.13l08745

11. United States Food and Drug Administration approved labelling. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/211243s004lbl.pdf (Accessed on August 10, 2020).