Tuesday, December 24, 2019

Treatment resistant depression notes

Hi! Quick notes for a friend :)

Treatment resistant depression: Major depressive episodes that do not respond satisfactorily to at least two trials of antidepressant monotherapy.

Things to consider:
Assess adherence
Identify comorbidities
Reassess diagnosis

Treatment strategies:
Augmentation (adding a treatment)
Switching treatment

Augmentation with pharmacotherapy:
Second-generation antipsychotics
Second antidepressant from a different class
Thyroid hormone

Switching to a different treatment:
A different antidepressant
Transcranial magnetic stimulation

Selective serotonin reuptake inhibitor (eg, sertaline or citalopram) are usually first line drugs.
A different antidepressant:
Serotonin-norepinephrine reuptake inhibitors (eg, venlafaxine)
Atypical antidepressants (eg, bupropion or mirtazapine)
Tricyclic antidepressants (eg, imipramine or nortriptyline)
MAOIs (eg, phenelzine or tranylcypromine)
Serotonin modulators (eg, vortioxetine or vilazodone)

A different therapy:
Cognitive-behavioral therapy
Psychodynamic psychotherapy

Severe treatment resistant depression:
Electroconvulsive therapy (ECT)
Intravenous ketamine or intranasal esketamine

Indications for ECT as first-line treatment:
Persistent suicidal ideation with intent
Severe weight loss, malnutrition, or dehydration secondary to refusal of food and fluids
Malignant catatonia


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