Most patients in acute depression trials fail to achieve remission with antidepressant monotherapy. Many patients seem to require more than one medication to achieve remission or adequate response. Augmentation strategies are commonly used in clinical practice, but most have been poorly studied. In addition, better-studied strategies, such as the use of lithium and thyroid augmentation, have not been well investigated in combination with newer antidepressants. Various novel strategies are being investigated as augmenting agents, including selective dopamine agonists, sex steroids, norepinephrine reuptake inhibitors, glucocorticoid-specific agents, and newer anticonvulsants. We review the status of augmentation strategies in the treatment of depression.
"The most commonly used combination agent is bupropion , and though its frequency of such usage probably exceeds the available evidence, there is some support for its role as a combination agent . There are several likely reasons why bupropion is such a common combination agent: it is generally a well-tolerated medication , it can provide some benefit in counteracting the sexual side effects of the SSRIs, and its presumed mechanism of action as an indirect norepinephrine agonist and dopamine reuptake blocker is, in theory, an attractive accompaniment to the action of SSRIs . After bupropion, the next most common combination agent is mirtazapine . "
[Show abstract][Hide abstract] ABSTRACT: The current definition of remission from major depressive disorder does not fully take into account all aspects of patient recovery. Residual symptoms of depression are very common in patients who are classified as being in remission. Patients with residual symptoms are at increased risk of functional and interpersonal impairments, and are at high risk for recurrence of depression. This article discusses the incidence of residual symptoms of depression, as well as the risks and consequences of these symptoms, and will review the state of current treatment.
[Show abstract][Hide abstract] ABSTRACT: Unipolar depression should be viewed as a chronic illness with multiple phases rather than as a relapsing-remitting disorder. Incomplete remission from depression is common, with approximately one third of patients continuing to have residual depression at remission. Patients who have had a depressive episode spend more time with residual depressive symptoms than with major depression long term. The presence of residual symptomatology after an episode of depression is associated with an increased risk of short-term relapse, a long-term chronic course, higher risk of suicide attempts, poor social functioning, and poor outcome of comorbid medical illnesses.
Current Psychiatry Reports 01/2006; 7(6):441-6. DOI:10.1007/s11920-005-0065-9 · 3.24 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Major depression is believed to be a multifactorial disorder involving predisposing temperament and personality traits, exposure to traumatic and stressful life events, and biological susceptibility. Depression, both unipolar and bipolar, is a "phasic" disease. Stressful life events are known to trigger depressive episodes, while their influence seems to decrease over the course of the illness. This suggests that depression is associated with progressive stress response abnormalities, possibly linked to impairments of structural plasticity and cellular resilience. It therefore appears crucial to adequately treat depression in the early stages of the illness, in order to prevent morphological and functional abnormalities. While evidence suggests that a severely depressed patient needs antidepressant drug therapy and that a non-severely depressed patient may benefit from other approaches (ie, "nonbiological"), little research has been done on the effectiveness of different treatments for depression. The assertion that the clinical efficacy of antidepressants is comparable between the classes and within the classes of those medications may be true from a statistical viewpoint, but is of limited value in practice. The antidepressant drugs may produce differences in therapeutic response and tolerability. Among the possible predictors of outcome in depression treatment, those derived from clinical assessment, neuroendocrine investigations, polysomnographic sleep parameters, genetic variables, and brain imaging techniques have been extensively studied. This article also reviews therapeutic strategies used when initial treatment fails, and describes briefly new concepts in antidepressant therapies such as the regulation of disturbances in circadian rhythms. The treatment of depressive illness does not stop with treatment of acute episodes, and has to be envisaged as a continuous therapeutic intervention, of which we are still not able to determine the optimal duration of treatment and the moment that it should be ceased.
Dialogues in clinical neuroscience 02/2006; 8(2):191-206.
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