It seems like an endless debate: When a patient does not respond to the first trial of an antidepressant, what should we do? Switch to something else? Augment with another agent? If the latter, how often should that augmenting agent be an atypical antipsychotic?

Ketamine has become increasingly popular as an off-label medication for rapid onset treatment of refractory depression. Recently, the American Psychiatric Association convened a task force to review the data and come up with some recommendations.

How do you start a new patient on antidepressant treatment? We do this countless times in our practices, and reviewing the topic may feel a bit like returning to residency. However, it’s important to revisit our standard operating procedures from time to time to ensure we’re thinking carefully about our decisions during our busy days.

You’ve tried different SSRIs and then some, but your patient either can’t tolerate what you’ve prescribed or simply hasn’t experienced a lift in mood. Now what? Dr. Gitlin has some ideas.

Your patient has now failed four antidepressant medications, both alone and as cocktails. What else can you pull out of your bag of tricks? Dr. Becker suggests considering transcranial magnetic stimulation (TMS), which he maintains is underutilized. “Many of my colleagues right down the hall from me still don’t think of TMS for treatment or don’t know who to refer for it,” he says. “I think it should be more readily considered for a lot of patients out there.”

For a look at how TMS works, how effective it is, how it compares with electroconvulsive therapy (ECT), whether some brands of TMS machines are better than others, and what you have to do to make sure your patient’s health insurance plan picks up the tab, we spoke with Dr. Becker, who prescribes this treatment for some of his patients.

We often prescribe antidepressants to patients who are suicidal, and unfortunately, some people use these very medications to try to kill themselves. It’s been known for some time that tricyclic antidepressants are among the most toxic in overdose, so we embraced the SSRIs and later medications in part because they are considered to be safer. But how safe are they?

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Dr. Simone Vigod describes her approach to prescribing medications during pregnancy. She starts by assessing the severity of the symptoms and the impact on function. Women usually fall into two categories: those who are not on medication and have become symptomatic, and those who have been taking medication, who are perhaps in remission, and are unsure about going off medication during pregnancy.

Atomoxetine was not originally included in that rogue’s gallery of medications, but since the drug was originally developed as an antidepressant, the FDA later reviewed its safety data. A post-hoc meta-analysis of placebo-controlled trials revealed an increased risk of suicidal thinking, and so atomoxetine was also slapped with a black box warning.