Skip to main content

Pharmacological Treatment Algorithm for Treatment Refractory Depression

Image
By

Pharmacological Treatment Algorithm for Treatment-Refractory Depression

These recommendations are based on the Maudsley Prescribing Guidelines 2018, according to which, depression is treatment refractory when it does not respond to sequential trials of three different antidepressants as recommended in their algorithms. 

In the first three steps below, we have enlisted the recommended pharmacological treatment options for an episode of depression. subsequently, we list the options for treatment-refractory depression. Maudsley Prescribing Guidelines focus on the pharmacological treatment options and algorithms, never nevertheless, they acknowledge the important role of non-pharmacological interventions in its treatment and recommend considering one of the appropriate options like cognitive behaviour therapy and/or behavioural activation and other factors identified as being responsible for resistance.

Step 1:

Recommend an SSRI or mirtazapine. monitor for signs and effects for 3- to 4 weeks. 

Step 2:

if no effects are appreciated, increase the dose, if appropriate (eg for escitalopram, sertraline etc) else, switch to another antidepressant (eg if the patient is on fluoxetine, where dose escalation does not produce any beneficial effects).  

Step 3:

Consider vortioxetine, agomelatine, or mirtazapine, if not already tried.
  1. Vortioxetine
  2. Agomelatine
  3. Mirtazapine

Fourth line 

Augment with either lithium or low-dose quetiapine/aripiprazole, OR Combine mirtazapine (with SSRI or venlafaxine), bupropion (with SSRI), olanzapine (with fluoxetine)
(or first line for refractory depression):

Mnemonic: AV BLOQ

● Aripiprazole augmentation
● Venlafaxine (in combination with mirtazapine)
● Bupropion (+SSRI)
● Lithium augmentation
● Olanzapine and fluoxetine
● Quetiapine augmentation

Next

  • Augment with anyone of an antipsychotic (risperidone), T3, buspirone, lamotrigine, OR
  • Give Ketamine IV or intranasal esketamine, OR
  • Start ECT, OR
  • Give high-dose venlafaxine (above 200mg)
Labels:

Comments

Post a Comment

Your Thoughts?

Popular posts from this blog

ADVOKATE: A Mnemonic Tool for the Assessment of Eyewitness Evidence

By
ADVOKATE: A Mnemonic Tool for Assessment of Eyewitness Evidence A tool for assessing eyewitness  ADVOKATE is a tool designed to assess eyewitness evidence and how much it is reliable. It requires the user to respond to several statements/questions. Forensic psychologists, police or investigative officer can do it. The mnemonic ADVOKATE stands for: A = amount of time under observation (event and act) D = distance from suspect V = visibility (night-day, lighting) O = obstruction to the view of the witness K = known or seen before when and where (suspect) A = any special reason for remembering the subject T = time-lapse (how long has it been since witness saw suspect) E = error or material discrepancy between the description given first or any subsequent accounts by a witness.  Working with suspects (college.police.uk)
Post a Comment
Read more

ICD-11 Criteria for Anorexia Nervosa (6B80)

By
ICD-11 Criteria for Anorexia Nervosa (6B80) Anorexia Nervosa is characterised by significantly low body weight for the individual’s height, age and developmental stage that is not due to another health condition or to the unavailability of food. A commonly used threshold is body mass index (BMI) less than 18.5 kg/m2 in adults and BMI-for-age under 5th percentile in children and adolescents. Rapid weight loss (e.g. more than 20% of total body weight within 6 months) may replace the low body weight guideline as long as other diagnostic requirements are met. Children and adolescents may exhibit failure to gain weight as expected based on the individual developmental trajectory rather than weight loss. Low body weight is accompanied by a persistent pattern of behaviours to prevent restoration of normal weight, which may include behaviours aimed at reducing energy intake (restricted eating), purging behaviours (e.g. self-induced vomiting, misuse of laxatives), and behaviours aimed at incr
Post a Comment
Read more

ICD-11 Criteria for Schizophrenia (6A20 )

By
ICD-11 Criteria for Schizophrenia (6A20 ) Schizophrenia is characterised by disturbances in multiple mental modalities, including thinking (e.g., delusions, disorganisation in the form of thought), perception (e.g., hallucinations), self-experience (e.g., the experience that one's feelings, impulses, thoughts, or behaviour are under the control of an external force), cognition (e.g., impaired attention, verbal memory, and social cognition), volition (e.g., loss of motivation), affect (e.g., blunted emotional expression), and behaviour (e.g., behaviour that appears bizarre or purposeless, unpredictable or inappropriate emotional responses that interfere with the organisation of behaviour). Psychomotor disturbances, including catatonia, may be present. Persistent delusions, persistent hallucinations, thought disorder, and experiences of influence, passivity, or control are considered core symptoms. Symptoms must have persisted for at least one month in order for a diagnosis of schi
Post a Comment
Read more