Treatment-Resistant Depression
ALISON LITTLE, MD, MPH, Oregon Health & Science University, Portland, Oregon
Am Fam Physician. 2009 Jul 15;80(2):167-172.
http://www.aafp.org/afp/2009/0715/p167.pdf
Depression is seen in up to 15% of the population, but only 60% get treatment. Of those treated, between 1/3 and 2/3's of the patients do not respond to initial treatment. Depression is considered treatment-resistant when failure occurs with at least two different drug classes (given for at least 8 weeks). Serum levels can be drawn to determine if the patient was properly taking and receiving an adequate dose. At this point, the clinician should go back and confirm the diagnosis. Comorbid disease treatment should be optimized as well. A psychotherapy consult may be warranted, even though effectiveness data is limited. Combination therapy may provide added benefit.
Different medication classes have different side effects. TCA's can cause cardiovascular, anticholinergic, sedation and weight gain issues. MAOIs can lead to malignant hypertension when mixed with certain foods. Venlafaxine can cause nausea and vomiting. Paroxetine can cause sexual side effects. Mirtazapine can cause weight gain. Sertraline can cause diarrhea.
The STAR*D trial was designed to treat resistant depression, where different combinations of medications were used in a stepwise manner to achieve remission. Patients who needed more steps were more likely to experience relapse. Only about half of the patients achieved sustained remission. ECT can be used when medication is contraindicated. It's major side effect is transient cognitive impairment. Vagal nerve stimulation has not shown benefit over placebo.
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