Treatment of Refractory Depression
When depression does not improve with three sequential trials of antidepressants, we call it treatment-refractory depression. the following is the list of choices for treatment-refractory depression.
First-line Treatment Options
- Bupropion 400 mg/d + SSRI
- Olanzapine + fluoxetine 25/50 mg/d
- Venlafaxine + mirtazapine 30-45 mg/d
- Add lithium, aim up to 1.0 mmol/L concentration.
- Add aripiprazole 2-20 mg/d
- Add quetiapine 150-300 mg/d
Ketamine-IV (0.5 mg/kg IV over 40 minutes),
à rapidly effective, by the anesthetist
High-dose venlafaxine à 200 mg/d,
à NICE recommended, monitor BP
à effective, stigmatized
Add risperidone 0.5-3 mg/d,
à weak evidence, hypotension
Add Triiodothyronine 20–50 μg/d,
à reasonable evidence, monitor TFTs
Lamotrigine, 100, 200, 400 mg/d,
à best tolerated, risk of rash
SSRI+ buspirone 60 mg/d,
à research-supported, dizziness at a high dose.
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