Using Adjunctive Treatments When First-Line Antidepressants Fail

Department of Psychiatry, University of Pennsylvania School of Medicine, PA, USA.
The Journal of Clinical Psychiatry (Impact Factor: 5.5). 01/2012; 73(1):e01. DOI: 10.4088/JCP.10126tx4c
Source: PubMed


Treatment-resistant depression is a common challenge for clinicians, as the majority of patients with depression do not achieve remission after an initial antidepressant trial. Major strategies for managing treatment-resistant depression include switching to another antidepressant or augmenting the initial antidepressant with another medication. Switching may be appropriate for patients experiencing little or no symptom relief or intolerable side effects with the initial antidepressant. For patients who experience partial response from the first-line antidepressant, adjunctive therapies avoid the loss of this response and the wash-out and cross-titration that are required when switching antidepressants. Several effective antidepressant augmentation agents are available, including lithium, thyroid hormone, anti-anxiety medications, and atypical antipsychotics. The evidence for the efficacy and risks of these strategies is discussed.

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    ABSTRACT: Les praticiens hospitaliers sont fréquemment confrontés aux dépressions résistantes pour lesquelles il existe plusieurs définitions et différents niveaux de résistance, selon que la rémission est partielle ou absente et selon l’évolution dans les étapes thérapeutiques. Les termes de résistance « relative » et « absolue » décrivent les degrés plus ou moins grands de certitude concernant l’adéquation d’un essai de traitement spécifique. Ce problème de l’adéquation nous a amené à préciser la clinique des dépressions résistantes, avec les différentes modalités de modification du tableau clinique, et à faire un retour sur l’expérience clinique qui met au jour les phénomènes endogènes de la dépression. Cette première étape permet de légitimer la recherche d’une stratégie médicamenteuse optimale, ou d’évoquer l’opportunité d’une stimulation cérébrale. Notre perspective clinico-phénoménologique se poursuit dans l’exploration des fausses résistances ou de ce qui peut apparaître comme tel. Nous abordons notamment le problème de l’articulation avec les comorbidités anxieuses, les comorbidités médicales, les addictions, les troubles de la personnalité et l’existence éventuelle d’une diathèse bipolaire. L’orientation thérapeutique met l’accent sur la stratégie médicamenteuse, et l’aide psychothérapeutique est détaillée en mettant en évidence les modalités d’un retour à l’équilibre avec l’appui d’une analyse des situations pathogènes tout en explicitant les difficultés d’une alliance thérapeutique authentique.
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    ABSTRACT: Hospital practitioners are regularly facing treatment-resistant depression, which may be defined according to the clinical picture or according to the therapeutic strategy. There are different levels of resistance and different levels of evidence for this resistance. Indeed, the notions of relative and absolute resistance describe the adequacy of assigned treatment. It thus seems necessary to specify the psychopathology of treatment-resistant depression and to highlight the endogeneity phenomenon in order to solve this problem. Our work addresses the concept of endogeneity (previously clarified by Hubertus Tellenbach) and will consider its implications in the management of treatment-resistant depression. We attempt to demonstrate that the phenomenological approach is an interesting tool in clinical practice through the highlight of endogenous characteristics. The first step consists in specifying the endogenous phenomena: abolition of rhythms, loss of the forward-looking deployment, overall impression, and reversibility, spatial and temporal characteristics from the phenotype. Our phenomenological approach continues by exploring the false resistances. Hence, we take into account anxious comorbidity, medical comorbidity, addictions, personality disorders and the hypothesis of a bipolar diathesis. First of all, it is difficult to show the patient in which way their behaviour results in stagnation. Indeed, it could strengthen the internal move that leads to an imperious necessity to cope with the surroundings. The psychotherapeutic help is elaborated by specifically highlighting the pathogenic situations whilst also taking into account the difficulties of an authentic therapeutic alliance. Our approach emphasizes the endogeneity phenomenon in depression, permitting the search for an optimal therapeutic strategy. It also provides assistance in resolving false resistance or what is apparent. In cases of endogenous depression, therapeutic orientation favours pharmacological and instrumental strategies (brain stimulation). If elements of self-understanding can be given to the patient, they must show that the rigid way in which the patient appropriates the daily reports is more stressful than the choice. Therefore, the psychotherapeutic help must take into account the situation and the individual vulnerability so as to develop a suitable care.
    No preview · Article · Sep 2013 · L Encéphale

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