Less common approaches. Many less commonly used antidepressant therapies are supported by anecdotal evidence only. They include light therapy (non-seasonal affective disorder), high-dose TCA or MAOI therapy (only if serum levels can be monitored), intravenous clomipramine or maprotiline (allows for rapid perfusion, avoids first pass liver metabolism), bromocriptine, high-dose selegiline, and psychosurgery. Modern stereotaxic psychosurgical procedures offer symptom relief with minimal risk, and reports of large trials indicate that up to ... Read More

Common strategies for treatment resistance. Electroconvulsive therapy An important and effective treatment for depression, electroconvulsive therapy (ECT) is effective in about 90% of cases of major depression. The success rate drops when it is used for drug-refractory cases. Using ECT depends on patient-related factors: it clearly is the treatment of choice for depression with psychomotor slowing, stupor, psychotic symptoms, or depression requiring rapid response because of suicidal risk or malnutrition. Use of ... Read More

If lithium augmentation is ineffective, it should be discontinued and the antidepressant changed (Table 5). A lack of response to one of the newer agents in a class, such as the selective serotonin reuptake inhibitors (SSRIs), does not predict lack of response to others in that class. If the first drug used was a reversible inhibitors of monoamine oxidase A (RIMA) with only one drug in the class, the ... Read More

Major depression is best managed through a treatment algorithm. The more resistant to treatment a patient's illness is, the further treatment proceeds through the steps. As each trial of therapy is deemed ineffective, diagnosis should be reviewed and physical and psychosocial factors reassessed before making a decision about the next step. Psychotherapy is an essential accompaniment to any form of somatic treatment. Supportive psychotherapy offers reassurance and time for patients ... Read More

Are there underlying physical factors? Many physical diseases present with depressive symptoms or complicate depressive illness (Table 2). Some of these illnesses remain undetected for years and account for an apparent treatment-resistant depression (TRD). Normal thyroid function is particularly important; even mild or subclinical hypothyroidism can impair response to antidepressants. Hypothyroidism can be induced by lithium therapy, and many drugs, both medical and nonmedical, can cause depression or complicate treatment (Table ... Read More

More than 20% of patients with major depression have not recovered after 2 years and, of those who do initially recover, 20% suffer a relapse 1 year later. Most studies have shown that 60% to 70% of patients respond to the first antidepressant used and a further 10% to 15% respond either to a second antidepressant or to electroconvulsive therapy (ECT). About 15% of patients fail to recover even with ... Read More

Depression treatment in the United States has been getting a bad name in a number of quarters recently. Patients who responded to Caredata.com's 1999 Commercial Health Plan Survey, for example, ranked treatment of depression as one of the most poorly rated of the 27 conditions studied. Of those respondents, 20% rated their depression care as "not adequate," and another 38% said it was only "adequate." Of the 74 health plans ... Read More

Question. I recently heard of the use of a low dose of Thorazine for the treatment of depression. Are you familiar with this treatment? Answer. I am not aware of any controlled, persuasive evidence that Thorazine (chlorpromazine) or any standard antipsychotic - in low doses or high - is particularly effective as an antidepressant. The exception to this claim may be in so-called delusional depression, in which psychotic features are present; ... Read More

Question. I have read several articles that refer to the use of certain types of music that is supposed to help people who suffer from depression, but none of them mention the specific type of music. Do you have any information or resources that lists specific music for therapy? Answer. Music has been used to treat various anxiety and stress-related states, including postoperative pain. However, in my literature search, I was ... Read More

Historically, St. John’s wort has been used as an herbal remedy for depression, anxiety, diuresis, gastritis and insomnia. Recent studies demonstrate that the extract, primarily hypericin, is a strong, and nearly irreversible, inhibitor of monoamine oxidase types A and B. Patient Presentation and History JS is a 37-year-old female who comes to the pharmacy intending to purchase St. John’s wort. She has heard that it can relieve depression, and she firmly believes ... Read More