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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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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Article Links

Risk Evaluation and Mitigation Strategy (REMS) Programs

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

Certain psychiatric treatments require both the healthcare provider and patient to enroll in a Risk Evaluation and Mitigation Strategy (REMS) program before they are administered. Below are links to enroll: Brexanolone (Zulresso) http://www.zulressorems.com/ Buprenorphine-based therapies (Suboxone, Subutex) https://www.samhsa.gov/medication-assi

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News of Note

Brexanolone (Zulresso) for Postpartum Depression

Topics: Depression | Depressive Disorder | Pharmacology | Postpartum Depression | Pregnancy

On March 19, 2019, the FDA approved brexanolone (Zulresso), the first medication for postpartum depression (PPD). Delivered by intravenous injection, brexanolone is an analogue of the hormone allopregnanolone. Allopregnanolone levels fall abruptly after childbirth, which is thought to contribute to PPD by destabilizing GABAA receptors. We covered brexa

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Research Update

Lithium in Geriatric Depression

Topics: Depression | Depressive Disorder | Geriatric Psychiatry | Lithium | Psychopharmacology | Treatment-Resistant Depression

REVIEW OF: Buspavanich P et al, J ­Affect Disord 2019;251:136–140 TYPE OF STUDY: Prospective, non-randomized controlled trial Augmentation with lithium has long been established as an effective strategy for refractory depression, but how does it fare in geriatric patients? There is a dearth of evidence on lithium in the geriatric population, which

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Research Update

Does TMS Really Work in Depression?

Topics: Depressive Disorder | Free Articles | Research Update

Review of: Yesavage et al, JAMA Psychiatry 2018;75(9):884–893 Type of study: Randomized, sham-controlled trial Repetitive transcranial magnetic stimulation (rTMS) has been FDA-approved for treatment-resistant depression (TRD) since 2008. This non-invasive therapy uses an electromagnetic coil to stimulate electrical activity in the frontal cortex

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Article

Behavioral Strategies for Suicide Prevention

Topics: Depressive Disorder | Free Articles | Psychotherapy

What can you do—beyond prescribing medications—to help your patients who have suicidal ideation? There are many strategies that you can teach your patients, even in the context of brief psychopharm visits. In this article, I’ll describe eight behavioral strategies that your patients are likely to find helpful. They are adapted from cognitive behav

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Article

Antidepressant-Induced Suicidality: What It Is and What You Should Do

Topics: Child Psychiatry | Depressive Disorder | Practice Tools and Tips

Do antidepressants actually cause children to be suicidal? If so, how do we detect it, and what should we do about it? In this article, we’ll give you a brief review of the most recent findings on antidepressant-induced suicidality (AIS) in children and adolescents, and then move on to some practical tips for how to evaluate and prevent this problem.

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