Treatment of Depression

Question 1

What are the neurostimulation options for depression and which are used clinically?

Answer 1

Used clinically
ECT
Vagus Nerve stimulation (Epilepsy)

Not used clinically
DBS (Parkinsonism) 2 failed trials

Repetitive Transcranial Stimulation (Limited evidence and accessibility

Ablative neurosurgery (<12)

Trans cranium direct current stimulation (Limited and not recommended,

Question 2

How many people receive prescriptions vs have depression?

Answer 2

61 Million vs 10% of population

Question 3

What is the difference between Remission and Response goals in depression treatment?

Answer 3

Remission:

Drop symptoms below threshold

HAM- 7, MADRS 10, QIDS 5

Response:

Report of efficacy

50% reduction in symptoms from baseline QIDS

Question 4

What can be an indicator of poor treatment response?

Answer 4

Residual symptoms

76 vs 24 %, or 3.4 times better

Question 5

What was the STAR *D algorithm and what did it find?

Answer 5

Stepped and progressive treatment plan for depression by John Rush in 2000s

2/3rds of patients had persistent depression

Most patients do not respond to first treatment

The chance of remitting decreases after each treatment attempt

Failure to remit increased chance of relapse

Question 6

What should be done when patients do not respond to treatment?

Answer 6

Reconsider Diagnosis

Increase:
If some response
Limited side effects
AntiDep has dose response

Change:
Side effects
No improvements
Quickly (unless interaction)
More than 1 failure (New class)
25% improvement

Augment treatment:
Partial response and good tolerability
Switching did not work
30% improvement 
Generally antispychotic (57%) and Lithium

Older people 50% to switch and Augment lithium best

Consider adherence

Question 7

What is the evidence that combining meds?

Answer 7

Limited