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What Is The Best Antidepressant For Treatment Resistant Depression
If a person with major depressive disorder (MDD) has not responded to at least two types of medication, they have treatment-resistant depression. This means that they have not experienced adequate relief from their symptoms after trying two different treatment methods.Although treatment-resistant depression can be difficult to manage, doctors have a variety of interventions to treat it. One choice involves changing from a first-line medication to an older antidepressant drug. Alternatively, a healthcare professional may add a non-antidepressant drug to a person’s medication regimen. They may also recommend psychotherapy, brain stimulation, or new drugs.Read more to learn about treatment-resistant depression, how doctors manage it, and more.Doctors classify cases of MDD as treatment-resistant depression when two antidepressants from two different drug classes do not relieve a person’s symptoms. According to a 2021 study published in the Journal of Clinical Psychiatry, 30.9% of people in the United States who take medication for their MDD have treatment-resistant depression. MDD, also called clinical depression, can cause:feelings of worthlessness and hopelessnesslow energy and motivationirritability and confusionpoor sleep, appetite, and sex driveThere are a variety of options used to manage treatment-resistant depression. A 2020 study discusses some of these methods, including adding drugs to a medication regimen, trying new drugs, psychotherapy, and more.Augmentation therapyThis involves adding a second medication to a first-line antidepressant. The additional medication is usually not an antidepressant.Current first-line medications include selective serotonin reuptake inhibitors (SSRI), such as citalopram (Celexa), and serotonin-norepinephrine reuptake inhibitors (SNRI), such as desvenlafaxine (Pristiq). The main augmentation medications include:Lithium (Priadel). This is a mood-stabilizing drug that doctors also use to treat bipolar disorder.Thyroid hormone. Thyroid levels can affect mood, and the thyroid hormone triiodothyronine (T3) may have activity within the brain and spinal cord. Doctors can prescribe the synthetic form of T3, liothyronine (Cytomel).Second-generation antipsychotics. These drugs treat conditions such as schizophrenia and borderline personality disorder (BPD). An example of an antipsychotic doctors use in augmentation therapy is quetiapine (Seroquel).Bupropion (Wellbutrin). This antidepressant does not act on serotonin receptors, so it can be safely added to SSRIs or SNRIs.Combining, optimizing, and changing classesA doctor may recommend changing medications, adjusting the dosage, or switching to a different class of drug.For example, if an SSRI or an SSNI is not effective, a doctor may prescribe an older class of drug, such as tricyclic antidepressants. An example of this type of drug is imipramine (Tofranil).A healthcare professional may also add another drug to a person’s medication regimen or increase their dosage.PsychotherapyDoctors may use psychotherapy alone or in combination with other drug or non-drug therapies. Examples of psychotherapy include cognitive behavioral therapy (CBT), which is identifying and changing unhealthy thought patterns, and interpersonal therapy, which focuses on improving interpersonal skills. These types of therapy can be valuable additions to a person’s treatment plan.Brain stimulationIf medication or psychosocial interventions are not effective, a doctor may prescribe brain stimulation. There are several types of brain stimulation. However, electroconvulsive therapy is the most effective. It involves the delivery of high-frequency electrical impulses to parts of the brain. Usually, they will recommend two to three sessions per week for a total of 6–18 sessions. New medicationsSome new medications may provide symptom relief for some people with MDD. In 2019, the Food and Drug Administration (FDA) approved esketamine (Spravato) for treatment-resistant depression. Doctors deliver this nasal spray to individuals in an office or clinic, and it quickly reduces symptoms in about half of people. However, esketamine has significant side effects, including high blood pressure and dissociative symptoms. Novel treatmentsSome people have success with psilocybin, the psychedelic in hallucinogen mushrooms. Its mechanism of action may be somewhat similar to first-line traditional medications, such as SSRIs, which increase levels of serotonin in the brain.Another novel treatment involves anti-inflammatory drugs. Researchers believe inflammation plays a role in treatment-resistant depression, so they may use anti-inflammatory drugs to treat it. Medications in this category may include cyclooxygenase-2 inhibitors (COX-2 inhibitors) such as celecoxib (Celebrex) and infliximab (Remicade). Older research from 2012 notes that a combination of risk factors contribute to treatment-resistant depression, including:Not staying on medication long enough. It can take 6–8 weeks for a drug to work properly, so if a person stops too early, their symptoms may not improve.Drug interactions. Some medications interact adversely or dangerously with antidepressants.Skipping doses. An person must take antidepressants according to the directions in order for them to work properly. For most medications, this means taking the drug daily.Genetic disorder. There is a genetic condition that prevents the synthesis of a substance the body needs to make serotonin.Alcohol or drug misuse disorders. These conditions can inhibit depression treatment.Co-occurring medical or psychiatric conditions. These conditions need treatment at the same time that a person receives treatment for depression.Wrong diagnosis. It is possible that someone has a condition other than treatment-resistant depression.Poor compliance. Environmental factors, such as a busy schedule or financial challenges, can affect treatment compliance.Older research indicates that unlike normal depression — which responds to typical treatment interventions — treatment-resistant depression manifests in:poor quality of lifefunctional impairmentself-harming behaviorhigh relapse ratesuicidal ideationAccording to research from 2012, more than one-third of people with treatment-resistant depression go into remission. The remainder have residual symptoms.However, a few studies suggest electroconvulsive therapy produces a higher rate of remission. One of these is an older 2004 clinical trial that investigated the effect of electroconvulsive therapy in 253 people with MDD. The results indicated that it produced remission in 75% of the participants.According to a 2020 study, experts do not fully understand how remission works. They still have much to learn about helping people reach and maintain remission.A diagnosis of treatment-resistant depression means a person has tried two different antidepressants that did not provide sufficient symptom reduction. About one-third of people with MDD have treatment-resistant depression.A doctor may recommend adding or changing medications, psychotherapy, electroconvulsive therapy, or new or novel medications.
Video about What Is The Best Antidepressant For Treatment Resistant Depression
Combinations for Treatment-Resistant Depression
Learn the essentials of psychopharmacology from Dr. Stephen Stahl! This clip from Stahl’s Essential Psychopharmacology, Video Edition covers potential treatment options for treatment-resistant depression. Learn more: https://nei.global/epvideos
Triple-action combo, such as SSRI/SNRI plus NDRI. Selective serotonin reuptake inhibitor (SSRI) plus a norepinephrine dopamine reuptake inhibitor (NDRI) leads to a single boost for serotonin (5HT), norepinephrine (NE), and dopamine (DA). Serotonin norepinephrine reuptake inhibitor (SNRI) plus a norepinephrine dopamine reuptake inhibitor (NDRI) leads to a single boost for serotonin (5HT), a double boost for norepinephrine (NE), and a single boost for dopamine (DA).
California rocket fuel: SNRI plus mirtazapine. Combining a serotonin norepinephrine reuptake inhibitor (SNRI) with mirtazapine is a combination that has a great degree of theoretical synergy: 5HT is quadruple-boosted (with reuptake blockade, alpha 2 antagonism, 5HT2A antagonism, and 5HT2C antagonism), NE is quadruple-boosted (with reuptake blockade, alpha 2 antagonism, 5HT2A antagonism, and 5HT2C antagonism), and there may even be a double boost of dopamine (with 5HT2A and 5HT2C antagonism).
About: In Stahl’s Essential Psychopharmacology: Video Edition, the newly published fifth edition of the landmark textbook comes to life as Dr. Stahl himself presents every chapter with fully animated illustrations. Learn more: https://nei.global/epvideos
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