CCNC Adult Depression Toolkit for Primary Care

Table of Contents Introduction .......................................................................................................................................... 1 Treatment Algorithm ............................................................................................................................ 2 Adult (>18 years) Depression Flow Chart (Generic) ................................................................................. 3 Adult (>18 years) Depression Flow Chart (Practice-Specific Workflow Example) .................................... 4 Overview of Care Process in the Treatment of Depression ...................................................................... 5 CCNC Depression Work Group Implementation Recommendations ....................................................... 6 Critical Decision Points (CDPs) for Acute Phase Treatment of Major Depression ................................... 7

Screening/Evaluation ......................................................................................................................... 9 PATIENT HEALTH QUESTIONNAIRE (PHQ-9) .................................................................................... 10 PHQ-9 Screening and Diagnosis ............................................................................................................ 11 Differential Diagnosis Screening ............................................................................................................. 12 SAMHSA ................................................................................................................................................. 13

Medication Information .................................................................................................................... 15 Quick Guide to Common Antidepressants .............................................................................................. 16 Antidepressants Side Effects Evaluation ................................................................................................ 18 Important Information About Your Depression Medication ..................................................................... 19

Documentation & Quality Improvement .......................................................................................... 20 Risk Factors for Depression .................................................................................................................... 21 Warning Signs for Depression ................................................................................................................ 21 DSM-5 Criteria for Major Depressive Episode ........................................................................................ 21 ICD-9/ICD-10 CODING ........................................................................................................................... 22 Depression Flow Sheet ........................................................................................................................... 23 Chart Review Tool for Depression .......................................................................................................... 24

Patient Education ............................................................................................................................... 25 Depression and You ................................................................................................................................ 26 Depression Self-Care Action Plan........................................................................................................... 28

Depression Support Resources: Telephonic/Care Management Follow-up ............................... 29 Role of the Phone Clinician in the Treatment of a Depressed Patient .................................................... 30 Phone Call Follow-Up Protocol in the Treatment of Depression ............................................................ 31 Phone Call Follow-Up Interventions for Clinicians .................................................................................. 32 Sample Scripts for Phone Call Interventions in the Treatment of Depression ........................................ 33 Depression: Phone Call Follow-Up ......................................................................................................... 36 Phone Clinician’s Phone Call Tracking Log ............................................................................................ 37

Spanish Language Resources ......................................................................................................... 38

2 PREGUNTAS PARA LA EVALUACIÓN DE LA DEPRESIÓN ........................................................ 39 LA DEPRESIÓN Y USTED ................................................................................................................... 40 EVALUACIÓN DE EFECTOS SECUNDARIOS DE ANTIDEPRESIVOS ............................................... 42 INFORMACIÓN IMPORTANTE ACERCA DE SU MEDICAMENTO ANTIDEPRESIVO ....................... 42 CUESTIONARIO DE SALUD DEL PACIENTE (PHQ-9) ........................................................................ 44

Network Specific Information ........................................................................................................... 45

Link to the full document can be found here: https://www.communitycarenc.org/media/relateddownloads/ccnc-depression-toolkit.pdf.

Introduction In the Spring of 2012, a Community Care of North Carolina (CCNC) workgroup comprised of Network Psychiatrists, Network Medical Directors, Pharmacists, Behavioral Health Coordinators, and representatives from area academic centers came together to create a toolkit designed to assist primary care providers in screening and treating adult depression in the primary care setting. This toolkit was adapted from an earlier version created by Community Care of Western Carolina (CCWNC), which was adopted from The MacArthur Initiative on Depression and Primary Care at Dartmouth & Duke, Version 9.0 -January 2004. This toolkit has now been revised and streamlined for 2015. This Toolkit is designed to help busy primary care practitioners access practical, evidence based tools to help them successfully treat depression in adults. It includes implementation recommendations, an overall algorithm to help with the initial assessment to determine severity and the corresponding recommended treatment approach, screening tools, critical decision points, medication recommendations, and many other useful guides. In addition, the toolkit highlights what to do when patients are not responding adequately, including when a referral to a psychiatrist for consultation would be indicated. Please let us know if you have questions or would like to be connected with your local CCNC resources. Warm Regards, CCNC Behavioral Health Integration Team

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Treatment Algorithm

Treatment Algorithm

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Adult (>18 years) Depression Flow Chart (Generic) Two Question Screen: PHQ-2 Annually, new adult patients, and when suspect

POSITIVE response on either 2 Question Screen or Clinical Concern; Administer PHQ-9

Physician Validation of Major Depressive D/O (MDD). R/O of medical and psychiatric conditions, i.e., Bipolar, substance abuse, normal grieving process, severe psychosocial problems SCORE NOT DUE TO OTHER CONDITIONS

Determine PHQ-9 total score: if 9 continue to ‘Physician Validation’

Minimal to mild depressive symptoms PHQ-9 score 5-9

 





Watchful Waiting*** Supportive Counseling Educate patient to call if condition deteriorates Repeat PHQ-9 at follow-up Consider referral if PHQ-9 scores fall in high risk areas

MAJOR DEPRESSIVE DISORDER MDD-Moderate PHQ-9 Score 10-14 MDD- Moderately Severe (PHQ-9) Score 15-19



 

  

MDD-Severe (PHQ-9 Score >20)

Consider referral, psychiatric consultation, or hospitalization if the patient: Is a risk to self or others Has had two failed medication trials, both trials with an adequate dose and duration of at least 6 weeks, if tolerated Exhibits psychotic symptoms or hx of bipolar disorder Has comorbid substance abuse Has severe psychosocial problems

MDD-Moderate/MDDModerately Severe; Recommend antidepressant and/or psychological counseling

MDD- Severe; Antidepressant strongly recommended with the addition of psychological counseling

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Adult (>18 years) Depression Flow Chart (Practice-Specific Workflow Example) Two Question Screen: PHQ-2 Annually, new adult patients, and when suspect; front desk staff distributes and scores

POSITIVE response on either 2 Question Screen or Clinical Concern; front desk staff notifies RN/ PA, administers PHQ-9 RN/PA screens for and R/O bipolar disorder, substance abuse, grieving, severe psychosocial problems and discusses with MD/NP

Determine PHQ-9 total score: if 5 continue to ‘Physician Validation’

Physician Validation of Major Depressive D/O (MDD). R/O of medical and psychiatric conditions, i.e., Bipolar, substance abuse, normal grieving process, severe psychosocial problems SCORE NOT DUE TO OTHER CONDITIONS

MAJOR DEPRESSIVE DISORDER Minimal to mild depressive symptoms PHQ-9 score 5-9

 





Watchful Waiting*** Supportive Counseling Educate patient to call if condition deteriorates Repeat PHQ-9 at follow-up Consider referral if PHQ-9 scores fall in high risk areas

MDD-Moderate PHQ-9 Score 10-14 MDD- Moderately Severe (PHQ-9) Score 15-19 

 

  

MDD-Severe (PHQ-9 Score >20)

Consider referral, psychiatric consultation, or hospitalization if the patient: Is a risk to self or others Has had two failed medication trials, both trials with an adequate dose and duration of at least 6 weeks, if tolerated Exhibits psychotic symptoms or hx of bipolar disorder Has comorbid substance abuse Has severe psychosocial problems

MDD-Moderate/MDDModerately Severe; Recommend antidepressant and/or psychological counseling

MDD-Severe; Antidepressant strongly recommended; consider the addition of psychological counseling

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Overview of Care Process in the Treatment of Depression STEP 1: SCREENING AND DIAGNOSIS  Display of risk factors and warning signs for possible Depressive Diagnosis  Completion of 2 QUESTION screening for all patients  Completion of PHQ-9 for patients with positive screening  Scoring PHQ-9 for diagnosis and severity  Additional Screening for Suicide Risk, Substance Abuse, Bipolar Disorder, Psychosis, or comorbidity as indicated with referral to a mental health provider for urgent/emergent cases STEP 2: TREATMENT SELECTION 1. Clinical Interview to identify previous history/treatment of depression or other mental health disorder 2. Utilize PHQ-9 Score and patient preference to drive selection of treatment plan: 1. Referral to Mental Health provider for Urgent/Emergent Care 2. Wait and Observe 3. Medication alone 4. Medication plus Counseling 5. Counseling alone 3. Referral to Clinical phone follow up for Education and Follow--‐Up Plan STEP 3: INITIATION OF TREATMENT PLAN  Provide the following: 1. Educational Materials with Verbal Instruction during office visit or by Phone Call and Mailing within 2. Provide assistance with obtaining medication (samples, sliding scale) to include written medication 3. Establish Treatment Care Plan with patient engagement 4. Schedule time for first clinical phone follow--‐up contact STEP 4: ACUTE PHASE FOLLOW-UP (See Clinical Decision Points (CDPs below)  1st FOUR MONTHS of treatment – Goal: achieve remission  Clinical phone call follow-up at set intervals per protocol, to include: 1. Documentation of repeat PHQ-9 to determine treatment response 2. Use of Medication Effectiveness/Side Effect Evaluation tool to determine patient's medication compliance and effectiveness of therapy if patient experiences sub-optimal response 3. Reminders to foster patient adherence to follow-up appointment schedule with Primary Care Provider schedule with Primary Care Provider (Initial Visit + 3 PCP/MHP Visits over the first 12 weeks of treatment is recommended by HEDIS)  Continued assistance with obtaining medication at no charge / reduced charge  Ongoing communication with PCP regarding patient's progress STEP 5: CONTINUATION AND MAINTENANCE CARE  Goal: Prevent relapse/recurrence  Continue pharmacologic and/or counseling treatment for: o 1st episode – 7 to 12 months of continuous pharmacotherapy o 2nd episode – 1 to 2 years OR lifetime with complicating factors o 3rd episode – lifetime therapy if all 3 episodes occur within one 5 year period  Provide patient education related to symptoms of relapse  Continue schedule of repeat PHQ-9 per phone call to monitor patient adherence to treatment plan and to provide support/re-teaching as needed  Ensure that patient is scheduled for further PCP visits if PHQ-9 scoring indicates recurrence/worsening of symptoms  PCP to determine patients at highest risk for need of Long Term Prophylactic Treatment  Follow patients requiring treatment > 6 months per protocol Primary Care Toolkit | September 2015 | Page 5

CCNC Depression Work Group Implementation Recommendations To meet the requirements for evidence based depression treatment in the primary care setting certain levels of “support” need be in place at a practice. Screening with a PHQ-9 for depression is not by itself sufficient to be considered evidence based care. However, in appreciation of the scarcity of resources at most practices the depression work group had as a goal to come up with the minimum requirements that a practice would need to have in place to meet that standard. These are: 



 

A practice based “champion” who would be responsible for organizing an “implementation team” that would include buy in from physicians, nursing, and administration. A community based psychiatrist who would be an identified provider and who would serve primarily as a resource to the practice assuring enhanced community psychiatric access (referrals would be seen quickly by this provider). This would likely NOT include phone consultation since there is no billing mechanism. It is possible the network psychiatrist could fill that role but this would need to be worked out by each network. Someone in the practice who could make follow-up phone calls and then track when patients are due for follow-ups as they go through the depression algorithm. A commitment to monitor how the program is working (primarily fidelity measures rather than patient outcomes at first; see Audit Tool for suggestions). The initial suggested fidelity measure would be the presence of a PHQ-9 having been completed at baseline for anyone who has had an anti‐depressant initiated (1st anti-depressant or change to a new anti-depressant).

We would suggest that each practice choose which specific patients to target for screening based on what would best fit their needs, and give the best chance for implementation success. Some possible choices are patients with diabetes, cardiovascular disease, patients already receiving anti-depressants, chronic pain patients, or high users of resources.

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Critical Decision Points (CDPs) for Acute Phase Treatment of Major Depression

CDP

WEEK 0 CDP #1

WEEK 1

PHQ-9 Baseline Severity Parameters

Treatment Modification

Initiate antidepressant medication at lower end of the dose range.

Severity ≥ 10

If severity >20 or clinical concern

Evaluate patient status, initial response to therapy, medication tolerance; if PHQ-9 question #9 (suicide) was +, conduct Suicide Screening and assessment; May be from trained physician, therapist, nurse, or care manager (If indicated return appointment scheduled prior to week 4.)

Recommended for all patients (Do PHQ-9)

Evaluate patient status, initial response to therapy, medication tolerance. Increase antidepressant dose to medium dose range, as tolerated. May be from trained physician, therapist, nurse, or care manager (If indicated return appointment scheduled prior to week 4.)

Phone Call

WEEK 2 Phone Call

WEEK 4

PHQ-9 ≤ 5

None

PHQ-9, >5 and 5 and 5 and 5 symptoms including question 1 or 2, + functional impairment

≥ 20

Sever Major Depression

* If symptoms present for > 2 years, chronic depression, or functional impairment is severe, remission with watchful waiting is unlikely. IMMEDIATE active treatment is indicated for Major Depression.

Acute Phase Continuation Phase

Three (3) Phases of Depression Treatment** Aims at minimizing depressive symptoms – typically first 3‐ 4 months of therapy Tries to prevent return of symptoms in the current episode – 4-12 months (Repeat PHQ-9 Q 4-6 months).

Tries to prevent return of symptoms within 2 years – 12-24 months Medication Therapy is recommended for at least 9 months after return to well state.

Maintenance Phase

** REFERRAL or co-management with mental health specialty clinician if the patient is: High Suicide Risk Bipolar Disorder Inadequate Treatment Response Complex Psychosocial Needs Other Active Mental Disorder Adopted from The MacArthur Initiative on Depression and Primary Care at Dartmouth & Duke, Version 9.0 -January 2004.

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Differential Diagnosis Screening Patient Name: _________________________

DOB: _________________________

Date: _____________

GRIEF REACTION SCREENING 1.

Did your most recent period of feeling depressed or sad begin after someone close to you died?

2.

If so, did the death occur more than 2 months ago?

YES

NO

YES

NO

YES

NO

If “NO” to first question, or if “YES” to both questions, treat the patient for depression. MANIA SCREENING ‐ rule out Bi Polar Disorder 1. Has there ever been a period of at least four days when you were so happy or excited that you got into trouble, or your family or friends worried about it or a doctor said you were manic? 2.

A “yes” response indicates potential bipolar disorder. Assess further for mania. Diagnostic criteria include the concurrent presence of at least 4 of the following symptoms (one of which must be the first symptom listed): a. b. c. d. e. f. g.

A Distinct Period of Abnormal, Persistently Elevated, Expansive, or Irritable Mood Less Need for Sleep Inflated Self-Esteem/Grandiosity More Talkative than usual (pressured speech) Distractibility Increased Goal-Directed Activity or Psychomotor Agitation Excessive involvement in pleasurable activities without regard for negative consequences ( e.g., buying sprees, sexual promiscuity)

ALCOHOL USE / ABUSE SCREENING (CAGE): 1. Have you ever felt you ought to CUT DOWN on your drinking? 2. 3.

Have people ANNOYED you by criticizing your drinking? Have you ever felt bad or GUILTY about your drinking?

4.

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (EYE‐OPENER)? Two or more “yes” responses are positive for possible alcohol abuse.

Action Taken:  Screening negative; no further action required  Positive Screening; medication prescribed  Positive Screening; medication prescribed and referral to staff for Phone Protocol  Positive Screening; patient referred to Mental Health Provider Name of MH Provider: Comments:

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ResouRces n

n

n

n

Download this card and additional resources at http://wwww.sprc.org Resource for implementing The Joint Commission 2007 Patient Safety Goals on Suicide http://www.sprc.org/library/jcsafetygoals.pdf sAFe-T drew upon the American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors http://www.psychiatryonline.com/ pracGuide/pracGuideTopic_14.aspx Practice Parameter for the Assessment and Treatment of Children and Adolescents with Suicidal Behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 2001, 40 (7 Supplement): 24s-51s

SAFE-T Suicide Assessment Five-step Evaluation and Triage 1 IDeNTIFY RIsK FAcToRs Note those that can be modified to reduce risk

AcKNoWLeDGMeNTs n

n

Originally conceived by Douglas Jacobs, MD, and developed as a collaboration between Screening for Mental Health, Inc. and the Suicide Prevention Resource Center. This material is based upon work supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) under Grant No. 1U79SM57392. Any opinions/findings/conclusions/ recommendations expressed in this material are those of the author and do not necessarily reflect the views of SAMHSA.

National Suicide Prevention Lifeline

1-800-273-TALK (8255)

2 IDeNTIFY PRoTecTIVe FAcToRs Note those that can be enhanced

3 coNDucT suIcIDe INQuIRY Suicidal thoughts, plans, behavior, and intent

4 DeTeRMINe RIsK LeVeL/INTeRVeNTIoN Determine risk. Choose appropriate intervention to address and reduce risk

http://www.sprc.org

5 DocuMeNT Assessment of risk, rationale, intervention, and follow-up

HHS Publication No. (SMA) 09-4432 • CMHS-NSP-0193 Printed 2009

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration www.samhsa.gov

Suicide assessments should be conducted at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical change; for inpatients, prior to increasing privileges and at discharge. 1. RISK FACTORS 3 suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior 3 current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity) Co-morbidity and recent onset of illness increase risk 3 Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations 3 Family history: of suicide, attempts, or Axis 1 psychiatric disorders requiring hospitalization 3 Precipitants/stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g, loss of relationship, financial or health status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation 3 change in treatment: discharge from psychiatric hospital, provider or treatment change 3 Access to firearms

2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk 3 Internal: ability to cope with stress, religious beliefs, frustration tolerance 3 external: responsibility to children or beloved pets, positive therapeutic relationships, social supports

3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, intent 3 Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever 3 Plan: timing, location, lethality, availability, preparatory acts 3 Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self injurious actions 3 Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self-injurious. Explore ambivalence: reasons to die vs. reasons to live * For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition * Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above

4. RISK LEVEL/INTERVENTION 3 Assessment of risk level is based on clinical judgment, after completing steps 1–3 3 Reassess as patient or environmental circumstances change

RISK LEVEL

RISK/PROTECTIVE FACTOR

SUICIDALITY

POSSIBLE INTERVENTIONS

High

Psychiatric diagnoses with severe symptoms or acute precipitating event; protective factors not relevant

Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal

Admission generally indicated unless a significant change reduces risk. Suicide precautions

Moderate

Multiple risk factors, few protective factors

Suicidal ideation with plan, but no intent or behavior

Low

Modifiable risk factors, strong protective factors

Thoughts of death, no plan, intent, or behavior

Admission may be necessary depending on risk factors. Develop crisis plan. Give emergency/crisis numbers Outpatient referral, symptom reduction. Give emergency/crisis numbers

(This chart is intended to represent a range of risk levels and interventions, not actual determinations.)

5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, E.C.T., contact with significant others, consultation); firearms instructions, if relevant; follow-up plan. For youths, treatment plan should include roles for parent/guardian.

Medication Information

Medication Information

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Quick Guide to Common Antidepressants Medication

Therapeutic Dose Range (mg/day)

Initial Suggested Dose

Titration Schedule

Additional Information

Serotonin Reuptake Inhibitors (SSRIs) – All available as generic

20 mg in the morning FLUOXETINE (Prozac)

CITALOPRAM (Celexa®)

ESCITAL OPRAM (Lexapro®)

10-80

(10 mg in the elderly, patients with hepatic disorder & when treating panic disorder)

20-40

20 mg/day

May increase the dose to 40 mg after a minimum of 1 week. (max dose: 40 mg/day in patients 60 years and patients with hepatic impairment)

10-20

SERTRALINE (Zoloft®)

10 mg/day

25-200

50 mg/day

20 mg/day, preferably in the morning PAROXETINE (Paxil®)

May increase the dose by 10 to 20 mg/day every 7-14 days as tolerated.

10-50

(10 mg in the elderly & patients with severe renal or hepatic impairment)

Advantages: Long half-life is good for poor compliance; low risk for withdrawal syndrome. Capsules, tablets, oral solution, and delayed-release capsules are bioequivalent. Disadvantages: Slower onset of action. Higher risk for drug interactions due to cytochrome P450 inhibition. More likely to cause insomnia/agitation than other SSRIs Advantages: Low risk for drug interactions due to cytochrome P450 interactions. Disadvantages: Doses >40 mg are associated with prolonged QT interval. Avoid concomitant 2C19 inhibitors (i.e., cimetidine, omeprazole); if used with 2C19 inhibitors maximum dose is 20 mg/day. Limited range for dose escalation.

May increase dose to 20 mg after a minimum of 1 week.

Advantages: 2x more potent than citalopram. Low risk for drug interactions due to cytochrome P450 interactions. Disadvantages: Limited range for dose escalation.

Increase by 50 mg/day at intervals of at least 1 week as needed to a maximum dose of 200 mg/day.

Advantages: Low risk for drug interactions due to cytochrome P450 interactions; risk increases at doses >150 mg. Can be used for post-MI patients; proven safe for HF patients. Disadvantages: Greater GI side effects, especially diarrhea. Can be stimulating or sedating.

Increase by 10 mg/day at intervals of at least 1 week as needed to a maximum dose of 50 mg/day (max dose: 40 mg/day in the elderly & patients with severe renal or hepatic impairment).

Advantages: Tends to be more sedating than other SSRIs which may be beneficial for patients who have trouble sleeping. Disadvantages: High risk for drug interactions due to cytochrome P450 inhibition. Significant anticholinergic effects. May have more sexual dysfunction and weight gain. Short half-life can lead to withdrawal syndrome with abrupt treatment discontinuation. Pregnancy category D

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Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) – All available as generic

VENLAFAXINE IR and ER (Effexor and Effexor XR)

IR: 75–375

ER: 75-225

IR: 75 mg/day in 2-3 divided doses with food ER: 75 mg/day (May start with 37.5 mg/day for 4-7 days to allow patient to adjust to medication)

40-60 DULOXETINE (Cymbalta)

Max dose: 120 mg (Doses greater than 60 mg/day confer no additional benefit.)

Increase by increments of up to 75 mg/day every 4-7 days as tolerated.

Initial dosage should be given BID. 40-60 mg/day (20-30 mg twice daily)

May start with 30 mg daily for 1 week before increasing to 60 mg daily, to allow patients to adjust to the medication.

Advantages: Low risk for drug interactions due to cytochrome P450 inhibition. Daily dosing (ER). SNRIs can be effective for different pain syndromes. Disadvantages: BID or TID dosing (IR). May cause nausea, especially at treatment initiation. May  blood pressure at higher doses (>150 mg/day). Monitor blood pressure. Requires dose adjustments in renal and hepatic impairment. Advantages: Dosing may be daily or BID. SNRIs can be effective for different pain syndromes. Disadvantages: May cause N/V, sexual dysfunction, insomnia, dysuria. Not recommended for use in patients with hepatic impairment, CrCl