Evolving Management Strategies for Treatment-Resistant Depression - Episode 14
Dr Patricia Ares-Romero highlights the traditional classes of antidepressant therapies available, reacts to common treatment-related adverse events, and describes when each type of therapy is most appropriate within a patient’s treatment course.
Steven Levine, MD: Patricia, in your practice, if you’ve evaluated a patient whom you’ve diagnosed with depression, and you feel that a pharmacological option is appropriate, what are the traditional classes of antidepressants? What does their adverse-effect profile typically look like?
Patricia Ares-Romero, MD, FASAM: We have the SSRIs [selective serotonin reuptake inhibitors], which are the ones that most people go to first. Primary care physicians are usually the ones who go to them first. That’s usually the first-line treatment for most patients when they first come in if they have a major depression disorder, not treatment-resistant depression. They have a lot of adverse effects. There can be sedation. There can be issues with hypernatremia. I’ve seen patients experience that. The thing is that not all of them work the first time. We talked about that earlier in this conversation. We usually treat them with a first-line antidepressant. We also have SNRIs [serotonin-norepinephrine reuptake inhibitors] such as Effexor and Wellbutrin in our armamentarium. We usually treat them for 4 to 6 weeks. At adequate dose and treatment, it sometimes doesn’t work, so we switch to another class.
There are other things, such as tricyclics, which are the older ones and not used as much anymore, or the MAOIs [monoamine oxidase inhibitors], which most of the young physicians don’t use. They don’t have that specialty in using them, so they stay away from them, but they do work well for patients with depression. Then we have augmentation strategies. We augment with things such as lithium. There are also antipsychotic medications. Atypicals are also used for augmentation therapy.
There are these other things that we use. But usually when a patient comes to me with treatment-resistant depression, all these things have already been exhausted and used. This is when we turn to something like esketamine or ketamine or look at things like TMS [transcranial magnetic stimulation] or ECT [electroconvulsive therapy]. Because at this point, they’ve really struggled with this illness. They have all these other issues happening in their lives. Maybe they can’t get up to go to work, are having problems at home with their families, or can’t take their kids to school because they’re getting so depressed. That’s when it’s time to use something else, and we use these other modalities.
Transcript Edited for Clarity