Treatment-Refractory Depression

Autor: Madhukar H. Trivedi, Beverly A. Kleiber, Tawny L Bettinger
Rok vydání: 2004
Předmět:
Zdroj: Antidepressants: Past, Present and Future ISBN: 9783642621352
DOI: 10.1007/978-3-642-18500-7_16
Popis: Despite the availability of many newer antidepressant medications, a significant percentage of patients are partial responders or have treatment-resistant depression (TRD). In such cases, there are very few data to indicate what step (combination, augmentation, or switching) should be taken next. The first step in optimizing treatment is to provide an antidepressant trial of adequate duration at a dosage that ensures therapeutic plasma levels. Some patients, including previous nonresponders, may benefit from higher doses. Although a medication trial of 4–8 weeks is often adequate to see some treatment response, patients with TRD may require a longer trial (e.g., 12–16 weeks) to achieve a full response. A framework of time-driven prompts called “critical decision points” can be helpful in determining the appropriate “next step” in treatment of TRD. At each decision point, the clinician assesses a patient's overall improvement and side effect burden and may choose to continue the prescribed dose, increase or decrease the dose, augment treatment with another agent, switch or combine medications. Switching medications is advantageous when there is a need to keep treatment simple or patient compliance is an issue. When a patient partially responds to a given treatment, the clinician should consider augmentation before switching. Potential advantages of augmentation include attaining full response without starting a new medication trial, using lower doses of both agents to minimize side effects, treatment of comorbid disorders such as subclinical hypothyroidism, and quicker treatment response. Combination therapy allows the clinician to treat depression with antidepressant medications that have differing mechanisms of action, thus affecting different neurotransmitter systems. The chapter provides a thorough description of medication use in each of these treatment strategies, including appropriate dosing, switching guidelines, augmentation strategies, and possible drug interactions. Clinical evidence in the literature (or the lack thereof) that support these therapies are reviewed. Alternative treatments to medication are discussed, including psychotherapy (e.g., cognitive behavioral therapy), electroconvulsive therapy (ECT), vagus nerve stimulation, and repetitive transcranial magnetic stimulation (rTMS).
Databáze: OpenAIRE
Externí odkaz: