The Journal of clinical psychiatry
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A substantial proportion of depressed patients show only partial or no response to antidepressants, and even among responders to antidepressant treatment, residual symptoms are rather common. When depressions do not respond adequately to treatment with an antidepressant, clinicians may choose to keep the same antidepressant and add another "augmenting" compound. Such augmentation strategies involve the use of a pharmacologic agent that is not considered to be a standard antidepressant but may boost or enhance the effect of an antidepressant. ⋯ These strategies typically aim at obtaining a different neurochemical effect than the one obtained with the antidepressant that has not produced adequate response. While drug-drug interactions may limit the use of some of these strategies, the potential loss of partial benefit from the failed drug inherent in switching may increase the acceptability of augmentation and combination strategies among partial responders. Further studies are clearly needed to evaluate the comparative efficacy and tolerability of these different approaches in treatment-resistant depressions.
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Chronic depression, which is marked by a course of illness lasting 2 years or more, encompasses 4 subtypes of depressive illness: (1) chronic major depressive disorder, (2) dysthymic disorder, (3) dysthymic disorder with major depressive disorder ("double depression"), and (4) major depressive disorder with poor interepisodic recovery (i.e., in incomplete remission). In the 1990s, chronic depression had a reported prevalence rate of 3% to 5% and accounted for 30% to 35% of all cases of depression in the United States. The authors present an algorithm modified from the Texas Medication Algorithm Project for patients with chronic depression. ⋯ The first stage is monotherapy with the selective serotonin reuptake inhibitors, nefazodone, bupropion sustained release, venlafaxine extended release, mirtazapine, or psychotherapy. Later options include combination therapy, electroconvulsive therapy, atypical antipsychotics, and novel treatments. Utilization of a comprehensive treatment algorithm for chronic major depression should encourage efficient, efficacious treatment.
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Both benzodiazepines and conventional anticonvulsants have been evaluated as treatments for social phobia (social anxiety disorder). Among the benzodiazepines, clonazepam is the best studied, although there is reason to expect that all benzodiazepine anxiolytics would be effective for this condition. Among the anticonvulsants, gabapentin and pregabalin, an analogue of gamma-aminobutyric acid (GABA), have been shown to be more effective than placebo in double-blind studies. Other than a small negative open study of valproic acid for social phobia, there is a paucity of information on whether other anticonvulsants might be useful for this condition.
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The art of psychopharmacology derives from the science of psychopharmacology, but still requires wisdom, judgment, and experience to translate findings from clinical trials of a new drug into clinical practice.