Depressive Disorder

Expert Q&A

Getting Uncomfortable with Esketamine

Topics: Antidepressant Augmentation | Antidepressants | Brain Devices | Depression | Depressive Disorder | ECT | Esketamine | Free Articles | Ketamine | Neurotoxicity | Novel Medications | rTMS | Suicidality | TMS | Transcranial Magnetic Stimulation | Treatment-Resistant Depression

Esketamine (Spravato) was approved for treatment-resistant depression in 2019. In this interview, Dr. Williams (who has no relationship with Janssen Pharmaceuticals, Inc) addresses some lingering doubts that have been raised about the medicine. TCPR: Where does esketamine fit in the list of interventional therapies for depression, like repetitive tra

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Article

Antipsychotic Maintenance: How Long is Enough?

Topics: Antidepressant Augmentation | Antidepressants | Antipsychotics | Bipolar Disorder | Deprescribing | Depression | Depressive Disorder | Mania | Metabolic syndrome | Mood Stabilizers | olanzapine | Psychopharmacology | Psychopharmacology Tips | Risperidone | Side Effects | Tardive dyskinesia

Your 58-year-old patient started risperidone to augment lithium 2 years ago. It got her out of a severe mania, and she has stayed well since then. Now she’s worried about long-term risks and wondering if it’s time to come off. Augmentation with an atypical antipsychotic may offer rapid relief from mania and depression, but antipsychotics’ potenti

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Research Update

TMS: Deeper is not Better

Topics: Depression | Depressive Disorder | Pharmaceutical Industry | Research Update | rTMS | TMS | Transcranial Magnetic Stimulation | Treatment-Resistant Depression

REVIEW OF: Filipcic I et al, J Psychiatr Res 2019;114:113–119 TYPE OF STUDY: Randomized single-blind controlled trial Seven transcranial magnetic stimulation (TMS) devices are FDA approved for depression, but only one—the Brainsway—is distinctly different from the others. Brainsway uses a patented H1 coil that penetrates deeper into the cortex t

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Clinical Update

Trazodone: The Forgotten Antidepressant

Topics: Antidepressants | Depression | Depressive Disorder | extended-release | Pharmacology Tips | Psychopharmacology | Psychopharmacology Tips | Trazodone

If your practice is anything like mine, trazodone is your go-to hypnotic. As an antidepressant, it’s an afterthought, dismissed as ineffective or intolerable since its release in 1981. Four decades and over 200 clinical trials later, it’s a good time to see if we’ve missed any opportunities in this forgotten antidepressant. How trazodone worksTra

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Research Update

Psilocybin vs Escitalopram for Depression

Topics: Antidepressant Augmentation | Antidepressants | Depression | Depressive Disorder | Novel Medications | Psilocybin | Treatment-Resistant Depression

REVIEW OF: Carhart-Harris R et al, New Engl J Med 2021;384(15):1402–1411 STUDY TYPE: Randomized controlled trial Psilocybin is, among other things, a serotonin 2A agonist responsible for the psychedelic properties of magic mushrooms. Back in 1960, Sandoz (now Novartis) began marketing psilocybin to enhance the effects of psychotherapy, but produ

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Clinical Update

ECT Worked: Now What?

Topics: Antidepressant Augmentation | Depression | Depressive Disorder | ECT | Free Articles | Lithium | Treatment-Resistant Depression

Juan is a 72-year-old man with severe depression who has not responded to numerous antidepressant trials. He is reluctant to undergo a course of electroconvulsive therapy (ECT), but agrees to do so if one last medication trial doesn’t work. After failing to respond to escitalopram augmented with aripiprazole, Juan receives a course of ECT and has a te

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Research Update

Comparison of GI Side Effects of Antidepressants

Topics: Antidepressants | Depression | Depressive Disorder | Free Articles | Mirtazapine | Side Effects | SNRIs | SSRIs

REVIEW OF: Oliva V et al, Prog Neuropsychopharmacol Biol Psychiatry 2021;109:110266 TYPE OF STUDY: Meta-analysis of placebo-controlled trials Antidepressants often cause gastrointestinal (GI) side effects, but it’s not clear which ones are the worst actors. A recent meta-analysis helps to clarify the picture. The investigators searched the li

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Expert Q&A

Psychotherapy and Medication in Recurrent Depression

Topics: Brief psychotherapy | Deprescribing | Depression | Depressive Disorder | Prevention | Psychotherapy | Therapy during medication appointment | Therapy with Med Management | Treatment-Resistant Depression

TCPR: When depression is recurrent, we usually continue the antidepressant indefinitely. Has that practice come under challenge?Dr. Fava: Yes. Antidepressant drugs are certainly important during the depressive episode, but what we are starting to question is whether they are as effective in preventing relapse. A meta-analysis from 12 years ago found tha

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Expert Q&A

Probiotics in Psychiatry

Topics: Alternative treatments | C-Reactive Protein | Complementary treatments | CRP | Depression | Depressive Disorder | Exercise | Inflammation | Mind-Gut Connection | Natural Medications | natural treatments | Nutrition | Obesity

TCPR: What is the gut microbiome? Dr. Dinan: It is the collection of microorganisms within the intestine. It functions like a separate organ and is about the same weight as an adult brain. Mainly it’s made up of bacteria, which is where our research has focused, but there are viruses and fungi in there as well. The traditional view was that these org

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Expert Q&A

Mood and Menopause

Topics: Antidepressants | Citalopram | Depressive Disorder | Effexor | Escitalopram | Female Issues in Psychiatry | Fluoxetine | gabapentin | Gender | Hormone Replacement Therapy | Oral Contraceptives | Prozac | Serotonin Specific Reuptake Inhibitors (SSRIs) | SSRIs | Women’s Issues in Psychiatry

TCPR: When does perimenopausal depression tend to start?Dr. Nonacs: It’s during the transition into menopause that women are most vulnerable to depression. And that transition can actually take quite a while, like 5–7 years. TCPR: How does it present?Dr. Nonacs: Often they’ve had a history of depression, but have done fairly well up to this point

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Expert Q&A

When Further Medication Trials Seem Futile

Topics: Depression | Depressive Disorder | MAOIs | Patient relationship | Pramipexole | Psychiatric interviewing | Therapy during medication appointment | Therapy with Med Management | Treatment-Resistant Depression

TCPR: When it comes to medication trials, how do you know when enough is enough?Dr. Goldberg: I don’t think I would ever say “enough is enough,” but there is a point at which the probability of medicines having a big effect becomes very, very low. In depression, that point is pretty black-and-white in my mind: 5 trials. In a study from Massachuset

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Expert Q&A

The Psychopharmacology Algorithm Project

Topics: Antidepressant Augmentation | Antidepressants | Antipsychotics | Bipolar Disorder | Bupropion | Depression | Depressive Disorder | Escitalopram | Lamictal | Lamotrigine | Lithium | Mood Stabilizers | olanzapine | Psychopharmacology | Psychopharmacology Tips | Wellbutrin

TCPR: What would be the biggest change in practice if psychiatrists followed your algorithms?Dr. Osser: One area is bipolar depression. This is a disorder where there is an exceptionally large deviation between what the evidence says and what people are doing, especially when it comes to antidepressants. They are still being used rampantly, even in pati

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Research Update

Optimal Antidepressant Doses in Major Depression

Topics: Antidepressants | Bupropion | Citalopram | Depression | Depressive Disorder | Escitalopram | Fluoxetine | Mirtazapine | Paroxetine | Pharmacology | Pharmacology Tips | Research | Research Update | Sertraline | SSRIs | Venlafaxine | Wellbutrin

Review of: Furukawa TA et al, Lancet Psychiatry;2019;6(7):601–609 Type of study: Systematic review and meta-analysis Most antidepressants do not have a linear response curve. In other words, the benefits level off as the dose goes up. If the dose gets too high, the side effects start to outweigh those diminishing returns. What’s not clear is whe

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Expert Q&A

Inflammatory Biomarkers in Depression

Topics: Bupropion | C-Reactive Protein | CRP | Depression | Depressive Disorder | Dopamine | Exercise | Inflammation | Laboratory Testing in Psychiatry | Medical Comorbidities | Norepinephrine | Nortriptyline | Nutrition | Obesity | Treatment-Resistant Depression | Wellbutrin

TCPR: What is inflammation? Dr. Miller: Inflammation is the body’s natural response to infection or wounding. It’s important for survival, but if it goes on too long it damages the body in various ways. It contributes to heart disease, cancer, metabolic disorders, and neurodegenerative disorders. Ultimately, it can change set points in the brain th

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Highlights

Highlights From This Issue

Topics: Bupropion | C-Reactive Protein | CRP | Depression | Depressive Disorder | Dopamine | Exercise | Inflammation | Laboratory Testing in Psychiatry | Medical Comorbidities | Norepinephrine | Nortriptyline | Nutrition | Obesity | Treatment-Resistant Depression | Wellbutrin

Inflammation contributes to treatment resistance in depression and can be measured with a blood test, C-reactive protein (CRP). An elevated CRP predicts a favorable response to certain antidepressants, as well as specific lifestyle interventions. Nuedexta’s expanded use in dementia is based on questionable efficacy, but it is safer than many

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Research Update

An Answer for Psychotic Depression

Topics: Antidepressants | Antipsychotics | Deprescribing | Depression | Depressive Disorder | olanzapine | Pharmacology | Pharmacology Tips | Psychosis | Psychotic Depression | Research | Research Update | Tardive dyskinesia

REVIEW OF: Flint AJ et al, JAMA 2019;322(7):622–631 TYPE OF STUDY: Randomized, placebo-controlled trial Psychotic features in depression indicate a more severe form of the disease, with a higher risk of hospitalization and double the rate of disability compared with non-psychotic depression. A combination of an antipsychotic and an antidepressant is

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Clinical Update

A Practical Guide to Light Therapy

Topics: Alternative treatments | Bipolar Disorder | Complementary treatments | Depression | Depressive Disorder | Light and Dark Therapy | Light therapy | Lightbox | natural treatments | Seasonal Affective Disorder

Outdoor living, morning light, evening darkness, and regular rhythms of sleep and waking all have one thing in common: They prevent depression. That’s the conclusion of many large epidemiologic studies, but for people who work indoors and wake up to dark winter mornings, this isn’t good news (Asai Y et al, J Affect Disord 2018;241:235–240). Here

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Article

Mirtazapine Augmentation: Running Low on Rocket Fuel

Topics: Antidepressant Augmentation | Antidepressants | Depression | Depressive Disorder | Mirtazapine | Pharmacology | Pharmacology Tips | Psychopharm Myths | Psychopharmacology | Psychopharmacology Tips | SSRIs | Treatment-Resistant Depression | Venlafaxine

Adding mirtazapine (Remeron) to a serotonergic antidepressant is a popular augmentation strategy. When added to venlafaxine, the combo was thought to possess a particularly potent synergy that Stephen Stahl called “California Rocket Fuel.” However, the strategy has failed in a handful of new studies, some of them much larger than the original data.

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Article

l-Methylfolate for Depression: Costly Mistake or Good Thinking?

Topics: Antidepressants | CAM Treatments | Deplin | Depression | Depressive Disorder | Folate | Folic Acid | l-methylfolate | methylfolate | Natural Medications | Nutrition | Pharmacology | Pharmacology Tips | Psychopharmacology | Psychopharmacology Tips | Treatment-Resistant Depression

Folate (Vitamin B9) has a long track record as a low-cost, low-risk augmentation strategy in depression. It’s also available in a more expensive form, l-methylfolate (Deplin), that promises better results but at a premium price. So, is the cost worth it? Folate pathwaysFolate (the natural form of folic acid) is a B vitamin that’s important in psych

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Article

Esketamine Gets FDA Approval

Topics: Depression | Depressive Disorder | Esketamine | Pharmacology | Treatment-Resistant Depression

On March 5, 2019, the FDA approved esketamine (Spravato) nasal spray as add-on therapy to traditional antidepressant medications for treatment-resistant depression (TRD). In this article, I will describe the events that led to esketamine’s development, review the data submitted to the FDA, and discuss what the future might hold for esketamine. Backgr

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