Showing posts with label Refractory Depression. Show all posts
Showing posts with label Refractory Depression. Show all posts

Sunday, 10 January 2021

Pharmacological Treatment Algorithm for Treatment Refractory Depression

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)

Saturday, 9 January 2021

Treatment Options for Refractory Depression

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

  1. Bupropion 400 mg/d + SSRI
  2. Olanzapine + fluoxetine 25/50 mg/d
  3. Venlafaxine + mirtazapine 30-45 mg/d
  4. Add lithium, aim up to 1.0 mmol/L concentration. 
  5. Add aripiprazole 2-20 mg/d
  6. Add quetiapine 150-300 mg/d 

Second-line Choices

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

Electroconvulsive therapy

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. 

Sunday, 12 January 2020

Clinical Vignette: Management of a Patient with Treatment-Refractory Depression

Clinical Vignette: Management of a Patient with Treatment-Refractory Depression

Mr X is a known case of depressive illness for the last 1 year. He has stopped responding after two different groups of antidepressants were tried and has been labelled as a patient of treatment-resistant depression. 

  1. How will you assess the cause of this resistance?
  2. Write the treatment algorithm that you will follow for his management?
  3. If you had to start lithium in this case, what protocol would you follow to start it and how will you monitor it?

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