ECT Worked: Now What?

Topics: Antidepressant Augmentation | Depression | Depressive Disorder | ECT | Free Articles | Lithium | Treatment-Resistant Depression

Juan is a 72-year-old man with severe depression who has not responded to numerous antidepressant trials. He is reluctant to undergo a course of electroconvulsive therapy (ECT), but agrees to do so if one last medication trial doesn’t work. After failing to respond to escitalopram augmented with aripiprazole, Juan receives a course of ECT and has a te

Comparison of GI Side Effects of Antidepressants

Topics: Antidepressants | Depression | Depressive Disorder | Free Articles | Mirtazapine | Side Effects | SNRIs | SSRIs

REVIEW OF: Oliva V et al, Prog Neuropsychopharmacol Biol Psychiatry 2021;109:110266 TYPE OF STUDY: Meta-analysis of placebo-controlled trials Antidepressants often cause gastrointestinal (GI) side effects, but it’s not clear which ones are the worst actors. A recent meta-analysis helps to clarify the picture. The investigators searched the li

Psychotherapy and Medication in Recurrent Depression

Topics: Brief psychotherapy | Deprescribing | Depression | Depressive Disorder | Prevention | Psychotherapy | Therapy during medication appointment | Therapy with Med Management | Treatment-Resistant Depression

TCPR: When depression is recurrent, we usually continue the antidepressant indefinitely. Has that practice come under challenge? Dr. Fava: Yes. Antidepressant drugs are certainly important during the depressive episode, but what we are starting to question is whether they are as effective in preventing relapse. A meta-analysis from 12 years ago found t

Six Tips for Working With Older Adults

Topics: Benzodiazepines | Depression | Geriatric Psychiatry | Medical Comorbidities

In the US, 1 in 7 adults are over the age of 65, and the growth in this population is far outpacing the growth in geriatric psychiatrists. As a result, general clinicians are increasingly called on to provide the majority of care for older adults. In this article I’ll share some tips for working with this population. Tip 1: Communication Many olde

Probiotics in Psychiatry

Topics: Alternative treatments | C-Reactive Protein | Complementary treatments | CRP | Depression | Depressive Disorder | Exercise | Inflammation | Mind-Gut Connection | Natural Medications | natural treatments | Nutrition | Obesity

TCPR: What is the gut microbiome? Dr. Dinan: It is the collection of microorganisms within the intestine. It functions like a separate organ and is about the same weight as an adult brain. Mainly it’s made up of bacteria, which is where our research has focused, but there are viruses and fungi in there as well. The traditional view was that these org

Transcranial Direct-Current Stimulation in Depression Reconsidered

Topics: Brain Devices | Depression

Review of: Razza LB et al, Depress Anxiety 2020;37(7):594–608 Study Type: Meta-analysis of randomized sham-controlled trials Transcranial direct-current stimulation (tDCS) is a neuromodulatory intervention with putative benefits in depression. The device consists of a headband with two electrodes that delivers a weak electrical current across the br

When Further Medication Trials Seem Futile

Topics: Depression | Depressive Disorder | MAOIs | Patient relationship | Pramipexole | Psychiatric interviewing | Therapy during medication appointment | Therapy with Med Management | Treatment-Resistant Depression

TCPR: When it comes to medication trials, how do you know when enough is enough?Dr. Goldberg: I don’t think I would ever say “enough is enough,” but there is a point at which the probability of medicines having a big effect becomes very, very low. In depression, that point is pretty black-and-white in my mind: 5 trials. In a study from Massachuset

The Psychopharmacology Algorithm Project

Topics: Antidepressant Augmentation | Antidepressants | Antipsychotics | Bipolar Disorder | Bupropion | Depression | Depressive Disorder | Escitalopram | Lamictal | Lamotrigine | Lithium | Mood Stabilizers | olanzapine | Psychopharmacology | Psychopharmacology Tips | Wellbutrin

TCPR: What would be the biggest change in practice if psychiatrists followed your algorithms?Dr. Osser: One area is bipolar depression. This is a disorder where there is an exceptionally large deviation between what the evidence says and what people are doing, especially when it comes to antidepressants. They are still being used rampantly, even in pati

Optimal Antidepressant Doses in Major Depression

Topics: Antidepressants | Bupropion | Citalopram | Depression | Depressive Disorder | Escitalopram | Fluoxetine | Mirtazapine | Paroxetine | Pharmacology | Pharmacology Tips | Research | Research Update | Sertraline | SSRIs | Venlafaxine | Wellbutrin

Review of: Furukawa TA et al, Lancet Psychiatry;2019;6(7):601–609 Type of study: Systematic review and meta-analysis Most antidepressants do not have a linear response curve. In other words, the benefits level off as the dose goes up. If the dose gets too high, the side effects start to outweigh those diminishing returns. What’s not clear is whe

Inflammatory Biomarkers in Depression

Topics: Bupropion | C-Reactive Protein | CRP | Depression | Depressive Disorder | Dopamine | Exercise | Inflammation | Laboratory Testing in Psychiatry | Medical Comorbidities | Norepinephrine | Nortriptyline | Nutrition | Obesity | Treatment-Resistant Depression | Wellbutrin

TCPR: What is inflammation? Dr. Miller: Inflammation is the body’s natural response to infection or wounding. It’s important for survival, but if it goes on too long it damages the body in various ways. It contributes to heart disease, cancer, metabolic disorders, and neurodegenerative disorders. Ultimately, it can change set points in the brain th

How to Use Pramipexole

Topics: Depression | Parkinson’s Disease | Pramipexole

Pramipexole is a selective agonist at the dopamine D3 receptor, which is thought to regulate hedonic drive. It is FDA approved in Parkinson’s disease and restless legs syndrome, and has five randomized controlled trials in depression. In unipolar depression it worked as monotherapy or augmentation, and in bipolar depression it worked as augmentation o

Highlights From This Issue

Topics: Bupropion | C-Reactive Protein | CRP | Depression | Depressive Disorder | Dopamine | Exercise | Inflammation | Laboratory Testing in Psychiatry | Medical Comorbidities | Norepinephrine | Nortriptyline | Nutrition | Obesity | Treatment-Resistant Depression | Wellbutrin

Inflammation contributes to treatment resistance in depression and can be measured with a blood test, C-reactive protein (CRP). An elevated CRP predicts a favorable response to certain antidepressants, as well as specific lifestyle interventions. Nuedexta’s expanded use in dementia is based on questionable efficacy, but it is safer than many

An Answer for Psychotic Depression

Topics: Antidepressants | Antipsychotics | Deprescribing | Depression | Depressive Disorder | olanzapine | Pharmacology | Pharmacology Tips | Psychosis | Psychotic Depression | Research | Research Update | Tardive dyskinesia

REVIEW OF: Flint AJ et al, JAMA 2019;322(7):622–631 TYPE OF STUDY: Randomized, placebo-controlled trial Psychotic features in depression indicate a more severe form of the disease, with a higher risk of hospitalization and double the rate of disability compared with non-psychotic depression. A combination of an antipsychotic and an antidepressant is

A Practical Guide to Light Therapy

Topics: Alternative treatments | Bipolar Disorder | Complementary treatments | Depression | Depressive Disorder | Light and Dark Therapy | Light therapy | Lightbox | natural treatments | Seasonal Affective Disorder

Outdoor living, morning light, evening darkness, and regular rhythms of sleep and waking all have one thing in common: They prevent depression. That’s the conclusion of many large epidemiologic studies, but for people who work indoors and wake up to dark winter mornings, this isn’t good news (Asai Y et al, J Affect Disord 2018;241:235–240). Here�

Highlights From This Issue

Topics: Addyi | Depression | Health Apps | Low libido | Vyleesi

Vyleesi and Addyi are FDA approved for low libido in women, but their benefits are modest and their risks give us pause. A host of anti-inflammatory medicines are effective in treatment-resistant depression, particularly celecoxib. Prescription apps have arrived, but Dr. Torous reminds us that the key ingredient in a mental health app is the therape

Anti-Inflammatories as Antidepressants?

Topics: Antidepressants | Depression | Inflammation | Novel Medications | Treatment-Resistant Depression

Review of: Köhler-Forsberg O et al, Acta Psych Scand 2019;139(5):404–419 Study Type: Meta-analysis of randomized controlled trials Several lines of evidence suggest that chronic inflammation contributes to depression. For example, markers of inflammation tend to be elevated in depressed patients, and inflammatory syndromes elicit depressive sym

Mirtazapine Augmentation: Running Low on Rocket Fuel

Topics: Antidepressant Augmentation | Antidepressants | Depression | Depressive Disorder | Mirtazapine | Pharmacology | Pharmacology Tips | Psychopharm Myths | Psychopharmacology | Psychopharmacology Tips | SSRIs | Treatment-Resistant Depression | Venlafaxine

Adding mirtazapine (Remeron) to a serotonergic antidepressant is a popular augmentation strategy. When added to venlafaxine, the combo was thought to possess a particularly potent synergy that Stephen Stahl called “California Rocket Fuel.” However, the strategy has failed in a handful of new studies, some of them much larger than the original data.

l-Methylfolate for Depression: Costly Mistake or Good Thinking?

Topics: Antidepressants | CAM Treatments | Deplin | Depression | Depressive Disorder | Folate | Folic Acid | l-methylfolate | methylfolate | Natural Medications | Nutrition | Pharmacology | Pharmacology Tips | Psychopharmacology | Psychopharmacology Tips | Treatment-Resistant Depression

Folate (Vitamin B9) has a long track record as a low-cost, low-risk augmentation strategy in depression. It’s also available in a more expensive form, l-methylfolate (Deplin), that promises better results but at a premium price. So, is the cost worth it? Folate pathwaysFolate (the natural form of folic acid) is a B vitamin that’s important in psych

A New Treatment for Bipolar Depression

Topics: Antipsychotics | Atypical Antipsychotics | Bipolar Depression | Bipolar Disorder | Depression | News of Note | Pharmacology | Psychopharmacology

On May 28, 2019, cariprazine (Vraylar) became the fourth atypical antipsychotic to receive FDA approval for bipolar depression. The approval was based on two randomized controlled trials involving 1,051 patients and lasting 6–8 weeks. These studies grouped patients into fixed doses from 0.75–3 mg/day. The sweet spot seems to be 1.5 mg/day, which was

Esketamine Gets FDA Approval

Topics: Depression | Depressive Disorder | Esketamine | Pharmacology | Treatment-Resistant Depression

On March 5, 2019, the FDA approved esketamine (Spravato) nasal spray as add-on therapy to traditional antidepressant medications for treatment-resistant depression (TRD). In this article, I will describe the events that led to esketamine’s development, review the data submitted to the FDA, and discuss what the future might hold for esketamine. Backgr