Treatment Resistant Depression

Question 1

Failure to respond to two or more antidepressants from different classes with adequate does, duration and compliance is?

Answer 1

TRD Treatment resistant depression

Question 2

Response that falls short of remission is associated with what 5 things?

Answer 2

Higher relapse
Poorer work productivity
Impaired psychosocial fxn
Higher levels of health care use
Higher risk for suicide

Question 3

Subtherapeutic doses of antidepressants, patient nonadherence, intolerable side effects, and wrong diagnosis are a number of conditions for the possible causes of what?

Answer 3

Relative or “pseudo” TRD

Question 4

Of all the factors associated with TRD, what two are the most prominent?

Answer 4

Anxiety and panic disorders

Question 5

This study’s primary goal was to see what drug or combination of drugs would lead to the highest percent of remission?

Answer 5

STAR*D

Question 6

Was there a placebo group in the STAR*D trial?

Answer 6

No, patients were given the choice between augmentation of meds and switching meds

Question 7

For level 1 of the STAR*D trial, all patients were started on what med and dose?

What is the max dose of that SSRI?

Answer 7

Citalopram (Celexa), 20mg

40mg

Question 8

For level 2 of the STAR*D trial patients could either switch to _______, ______ ______, ________, or ________. Or they could augment the citalopram (Celexa) with either ______, _______, or ________.

Answer 8

Switch: Bupropion (Wellbutrin), cognitive therapy, sertraline (Zoloft), venlafaxine (Effexor)

Augment: Buproprion (Wellbutrin) same as above but added on, buspirone (anxiolytic), cognitive therapy (same as above)

Question 9

Level 3 of STAR*D trial says to switch to ____ or ____, and to augment with ____ , _____, ____, and _____.

Answer 9

Level 3 Switch to mirtazipine (remeron) or nortriptyline

Level 3 augment w/ lithium, triiodothyronine, (only with bupropion, sertraline, venlafaxine)

Question 10

Patients had a _____% response rate to level 1 celexa, but only 1/3 of those completely remissed.

Answer 10

47% response to celexa alone in level 1

Question 11

What is the best predictor of whether or not a patient will respond to an ADM?

Answer 11

Early response

Question 12

What categories of patients had higher remission rates (were cured)?

Answer 12

Female
White
Employed
Higher levels of education
Insured
Shorter current episode
Fewer concurrent medical or psych disorders

Question 13

What patients required more treatments in the STAR*D trial?

Answer 13

Those who were more severely depressed
More concurrent psych and med disorders
Concurrent anxiety

Question 14

If level 1 citalopram (celexa) doesn’t provide complete remission, level 2 additions of Bupropion, sertraline, and venlafaxine are provided and celexa is discontinued (switch, not augment). What were the results?

Answer 14

All of the new meds had about a 25% remission for the L-2 switch from celexa

Question 15

For the L-2 augmentation with Bupropion or Buspirone addition, remission rates did what?

Answer 15

Bupropion jumped to 39% remission, and Buspirone to 32.90%, a markedly higher percent than the L-2 switch (25%)

Question 16

Unfortunately, we can’t extrapolate the L-2 augmentation with positive results of 39% for Bup and 33% for Bus because?

Answer 16

Patients who felt some positive response from Celexa were more likely to augment than switch

Question 17

For the L-2 cognitive therapy (CT), what did the switch and augmentation show?

Answer 17

Both about 25% remission, same as switching to a med (Bup, Ser, Venl). Also, CT took longer, 55 days compared to 26 with meds for remission.

Question 18

Level 3 switch to Mirtazipne or Nortriptyline showed relatively high/low remission when compared to L2 switch to Bup, Ser, Ven?

Answer 18

Low, 8 and 12% respectively

Question 19

Side note:

Mirtazipine (Remeron) is good for pts w/ GI issues or who are underweight. What pts is nortriptyline good for?

Answer 19

Pts w/ neuropathy or HA/migraines

Question 20

Level1 had remission rates of around 33%. Level 2 was 30%. What about L3/4?

Answer 20

13 and 14% respectively. First two steps saw much better rates of remission

Question 21

Sometimes you can augment treatment with a 2nd gen antipsychotic med, such as?

Answer 21

Olanzapine
Risperidone (Risperdal)
Quetiapine (Seroquel)
Aripiprazole (Abilify)

Question 22

All second gen antipsych meds were superior to placebo. Was one antipsych superior to another?

Answer 22

Nope, all equally effective w/in first 2 weeks

Question 23

What is the only med approved for post partum depression?

Answer 23

(Brexanolone) Zulresso

Question 24

Brexanolone, the only approved post-partum depression is administered how?

Answer 24

Infusion for 60hrs, showed rapid antidepressant effect with 65% reduction in depression sx

Question 25

How much does tx w/ brexanolone cost?

Answer 25

$34k (yup)

Question 26

What intranasal spray is approved for used for TRD in conjunction with an oral antidepressant?

Answer 26

Esketamine (spravato)

Only costs $5k/month

Question 27

What are some hippy-dippy naturopathic treatments for depression?

Answer 27

St John’s wort
Exercise
SAMe
Psilocybin
Omega-3 fatty acids (fish oil? Really?)
Vagus nerve stimulation
Transcranial magnetic stimulation
Ketamine