Take-home points

Many patients with depression and agitated features either do not respond to SSRIs or do not respond sufficiently to achieve functional independence, a return to vocation, or a social life. This patient had some symptom reduction but not a reduction in disability

Many patients with depression also do not respond to CBT, if available

Nevertheless, some patients can improve with pharmacologic approaches that have not been exhausted

In this case, high-dose antidepressant monotherapies, combinations, and augmentations were utilized, allowing a response eventually

In practice, this patient continues to try new combination and augmentation approaches in the hope of gaining remission

Performance in practice: confessions of a psychopharmacologist

What could have been done better here?

Is eclectic CBT less effective than manualized, research-based CBT?

• – This patient could have been referred for the latter or even a change in psychotherapy technique toward a dynamic or interpersonal approach

• – Sometimes, psychotherapy needs to be “dosed” like a medication in that once a full dose and duration is tried, clinicians have to admit treatment failure and aggressively move toward a new treatment or psychotherapy option

Should failure of the newer MAOI (selagiline patch) warrant a trial on an older “tried and true” MAOI such as phenelzine (Nardil) or tranylcypromine (Parnate)?

Should more bona fide approved augmentation strategies (quetiapine-XR or aripiprazole) been initiated before the less evidence-based ones used here?

Possible action items for improvement in practice

Research data for augmentation strategies that are not FDA approved

• – Determine if effect sizes are comparable, or not, to help guide future choices in TRD

Research available United States and international guidelines regarding TRD

• – These often compile a summary list, that is easier to interpret, of evidence-based treatments and the stringency of the available data to support their use

If this patient’s guilt was actually delusional in nature, achieving a reasonable dose of antipsychotic may have alleviated this and his other depressive symptoms

• – In this case, using an atypical antipsychotic sooner may have been warranted

Tips and pearls

The MAOI class of drugs is likely underutilized due to the overemphasized risk of hypertensive crisis and serotonin syndrome that surrounds their use

In this case, only a moderate dose of one MAOI was tried. There likely was room for other MAOI trials

Transdermal skin reactions in practice are difficult to treat and often fail to be relieved by oral/topical antihistamines or corticosteroids

MAOIs are clearly approved for treating depression but also have a good evidence base for treating social anxiety and atypical presentations of MDD

One negative to using MAOIs is the washout required between MAOI and other antidepressant trials

• – This often leaves patients unmedicated and prone to worsening of symptoms

• – Similar to switching among SSRI, SNRI, and TCAs, sometimes patients will respond to one MAOI better than another

Occasionally, patients can be treated with BZ anxiolytics or mood stabilizers during a washout to help avoid insomnia and agitation, at least to make the transition easier

However, certain typical and atypical antipsychotics have serotonergic and/or noreadrenergic potential, and despite not being officially contraindicated, probably should be avoided during washout or concurrent use of an MAOI (see following discussion)