Antidepressant Medication Prescribing Practices for Treatment of Major Depressive Disorder.

OBJECTIVE: The purpose of this study was to describe the prescribing practices of clinicians for patients with major depressive disorder (MDD). METHODS: This population-based, descriptive study of insured patients (N=54,107) identified people who were 18 years or older, had a claim for MDD, had at least one prescription for an antidepressant medication in 2013, and had continuous insurance coverage during the study period. Prescription claims were evaluated to determine the most commonly prescribed antidepressant medication and most common dose. RESULTS: The three most commonly prescribed antidepressant medications were citalopram (N=11,995, 22.2%), sertraline (N=10,791, 19.9%), and trazodone (N=9,501, 17.6%). The most common daily doses were 20 mg citalopram (N=6,304, 52.6%), 50 mg sertraline (N=4,173, 38.7%), and 100 mg trazodone (N=3,220, 33.9%). CONCLUSIONS: This is the first report of its kind that provides drug- and dosage-level details to demonstrate that antidepressant prescribing in clinical practice is largely within recommended guidelines.

A Comprehensive Review of Treatment Options for Premenstrual Syndrome and Premenstrual Dysphoric Disorder.

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome that involves a combination of emotional and physical symptoms that result in significant functional impairment. Because of the debilitating nature of PMDD, multiple treatment options have been considered. This review provides a comprehensive overview of these therapeutic regimens to help health care professionals provide adequate treatment for PMDD and premenstrual syndrome. The treatments that are reviewed are organized into the following categories: psychiatric, anovulatory, supplements, herbal, nonpharmacological, and other. Selective serotonin reuptake inhibitors have been established as the first-line treatment for PMDD. Although luteal phase or continuous dosing can be used, additional research is needed to more thoroughly compare the efficacies and differential symptom response of continuous, semi-intermittent, luteal phase, and symptoms-onset dosing. The psychiatric medications venlafaxine, duloxetine, alprazolam, and buspirone have also been found to be useful treatments for PMDD. Various anovulatory-related treatments have demonstrated efficacy; however, the use of some of these treatments remains limited due to potential side effects and/or the availability of cheaper alternatives. Although a variety of supplement and herbal-related treatments have been proposed, with some warranting further research, at this time only calcium supplementation has demonstrated a consistent therapeutic benefit. In conclusion, serotoninergic antidepressants have been established as the first-line treatment option for PMDD; however, there are a variety of additional treatment options that should be considered if a patient fails to achieve an adequate therapeutic response with a selective serotonin reuptake inhibitor.

Emergency ECT in an incapacitated, medically compromised patient with Huntington's disease.

Electroconvulsive therapy (ECT) is infrequently considered an "emergency" medical procedure; however, there are certain conditions in which there is considerable urgency to initiate ECT. For example, prompt administration of ECT to treat neuroleptic malignant syndrome and malignant catatonia is necessary to improve a patient's overall prognosis and potentially save the patient's life. In this case, a 57-year-old woman with Huntington's disease was admitted to our medical intensive care unit for failure to thrive due to severe psychotic symptoms. Prior to her admission, the patient had become increasingly psychotic and agitated, resulting in her refusal and/or inability to eat. Efforts to treat her severe psychiatric and behavioral symptoms with various psychopharmacological strategies were largely unsuccessful. As the patient's physical health continued to decline, with loss of approximately 35 pounds over 2 months, her family began making arrangements to transfer her to a hospice facility. The day before she was to be transferred, the psychiatry consultation-liaison service recommended ECT. Unfortunately, this recommendation was complicated because the patient was unable to provide consent. This case report describes the legal and administrative process used to ethically and legally administer ECT without consent from the patient or a court-appointed guardian in order to treat a life-threatening condition. To the best of our knowledge, this report documents the first time ECT has been granted "medical emergency" status in Texas.

Defining treatment-resistant depression: a comprehensive review of the literature.

BACKGROUND: Despite the common occurrence and debilitating nature of treatment-resistant depression (TRD), currently there is no universally accepted definition for TRD. This review summarizes the different methods used to define TRD, and provides an overview of the TRD literature. METHODS: PsycInfo, Medline, and Ovid were searched to identify relevant articles published in peer-reviewed journals. A combination and/or variation of the following keywords were searched: treatment resistant, treatment refractory, depression, defining, staging, and modeling. Identified articles provided a description of the methods utilized for defining and/or measuring TRD, prevalence and impact of TRD, risk factors for TRD, and/or factors that contribute to the misclassification of non-TRD patients. RESULTS: Multiple methods for defining/measuring TRD have been proposed; however, variability in these methods has limited the comparability between TRD studies. Although various risk factors for TRD have been suggested, few have been consistently supported. The misclassification of non-TRD patients as having TRD is related to various clinical and treatment-related factors. CONCLUSIONS: Adopting a universal standard definition for TRD is necessary to reduce the variability in how TRD is defined, and the misclassification of non-TRD patients. A universal definition would benefit clinical and research settings by allowing data to be easily compared across these settings.

Efficacy of right unilateral ultrabrief pulse width ECT: a preliminary report.

BACKGROUND AND OBJECTIVES: Ultrabrief (right unilateral) electroconvulsive therapy (UB-RU ECT) is a newer form of ECT, which uses a shorter pulse width than the standard ECT (0.3 vs 1.0 millisecond, respectively). As a result, the use of UB ECT may provide a means of further decreasing ECT-related cognitive adverse effects. In 2011, the University of Texas Southwestern Department of ECT in Austin adopted a UB ECT protocol. The purpose of this study was to perform a preliminary evaluation of the effectiveness and efficiency of UB-RU ECT. This study also examined whether sex, age, or diagnosis affected response rates. METHODS: This retrospective chart review identified 62 patients treated with the UB ECT protocol. An analysis of ECT response rates and demographic characteristics was conducted based on the data from clinical evaluations and Patient Health Questionnaire 9. RESULTS: Sixty-eight percent of patients in the study responded to ECT; 55% responded to UB pulse width RU ECT with another 13% responding when switched to standard pulse width bilateral ECT. The mean number of treatments in an index ECT series was 12.5. There was no statistically significant difference in response rates between bipolar and unipolar depressed patients. Men required progression to bilateral treatment more than women. CONCLUSIONS: This UB ECT protocol demonstrated a similar response rate when compared to standard ECT protocols; however, an increase in the number of treatments was required. Ultrabrief protocols are a viable option for both bipolar and unipolar depression. In men, UB ECT protocols may be less advantageous due to a need to overcome a potentially higher seizure threshold in men; however, additional research is needed to confirm this finding.

Advances in brain stimulation for depression.

BACKGROUND: Major depressive disorder is a common and debilitating psychiatric disorder that negatively impacts a large portion of the population. Although a range of antidepressant treatments have been developed, many patients are unable to obtain an adequate therapeutic response despite completing several antidepressant medication trials. As a result, neurostimulation treatment modalities have been developed as potential alternatives. This article provides an overview of advances in neurostimulation for treating depression. METHODS: We conducted a comprehensive review of the neurostimulation literature to identify recent findings involving the description and rationale, efficacy, and side effects of vagus nerve stimulation (VNS), transcranial magnetic stimulation (TMS), magnetic seizure therapy (MST), and deep brain stimulation (DBS). RESULTS: VNS and TMS are the newest neurostimulation modalities that have been approved by the FDA for treating depression. VNS is approved for patients with treatment-resistant depression (TRD), while TMS has demonstrated efficacy only for milder forms of TRD. Despite demonstrated efficacy, further research is needed to address certain limitations and/or determine how best to utilize these forms of neurostimulation. Investigational forms of neurostimulation include MST and DBS. Although MST and DBS have demonstrated promise as a depression treatment, research is still being conducted to determine and/or enhance their antidepressant properties. CONCLUSIONS: Although electroconvulsive therapy remains the primary and most effective treatment option for patients with severe TRD, there have been considerable gains in the field of neurostimulation. Many of the neurostimulation techniques described in this review represent promising treatment alternatives for patients with TRD.

The use of topical lidocaine to reduce pain during repetitive transcranial magnetic stimulation for the treatment of depression.

Repetitive transcranial magnetic stimulation (rTMS) is a form of neurostimulation therapy that was recently approved by the Food and Drug Administration for the treatment of depression. Repetitive transcranial magnetic stimulation is considered noninvasive and relatively safe; however, there have been reports of scalp pain during and at the site of stimulation. This case report documents the use of topical lidocaine to reduce scalp pain during rTMS administration. All patients had a diagnosis of major depressive disorder according to research diagnostic criteria and were washed off antidepressant medications before treatment. Patients were given active rTMS treatment during a masked, open-label, or long-term follow-up treatment schedule. Treatment was delivered to the left dorsolateral prefrontal cortex at 120% of the patient's observed motor threshold. Ten patients received 3000 magnetic pulses per session with an on time of 4 seconds and an off time of 26 seconds. Patients who reported pain during stimulation were given topical lidocaine HCl 2%, which was applied 20 minutes before treatment. Patients reported mixed outcomes of using topical lidocaine to reduce scalp pain during stimulation. Half of the patients reported no significant reduction in pain, whereas the other half indicated a noticeable decrease during rTMS. As a case report, our study has limited results. Given the recent approval of rTMS for the treatment of depression, additional studies are warranted to determine optimal methods of reducing scalp pain.

A review of continuation electroconvulsive therapy: application, safety, and efficacy.

Electroconvulsive therapy (ECT) is a neurostimulation therapeutic intervention that is highly effective and frequently used to treat certain psychiatric conditions, particularly major depressive disorder. Despite its high efficacy, a major limitation of ECT is the significant rate at which patients relapse after treatment. Providing additional ECT treatments after completion of a short-term course of ECT, referred to as continuation ECT (C-ECT), is a strategy used to reduce the risk of relapse. Specifically, C-ECT involves the administration of additional ECT treatments during the 6-month period after remission. This article summarizes the available literature regarding C-ECT including indication for use, patient selection, treatment guidelines/parameters, and safety. The efficacy of C-ECT is also discussed, with a focus on major depressive disorder and schizophrenia. On the basis of the current literature, indications for use and patient selection for C-ECT are predominately similar to those for a short-term ECT course. The treatment guidelines/parameters for C-ECT are recommended to be consistent with the parameters used to achieve remission, with the exception of greater intertreatment intervals during C-ECT. Although adverse cognitive effects can occur during C-ECT, the risk and severity of cognitive impairment are generally low, possibly because of the greater intertreatment intervals. Most research supports the use of C-ECT to prolong remission; however, methodologic limitations mitigate firm conclusions and generalizability of these findings. Nonetheless, the available evidence supports the use of C-ECT as a safe and effective method in relapse prevention.

Present and prospective clinical therapeutic regimens for Alzheimer's disease.

Alzheimer's disease (AD) is an incurable neurodegenerative disorder that produces cognitive impairments that increase in severity as the disease progresses. The clinical symptoms are related to the presence of neuritic plaques and neurofibrillary tangles in the cerebral cortex which represent the pathophysiological hallmarks of AD. The debilitating nature of the disease can result in clinical burden for the patient, emotional strain for those that care for patients with Alzheimer's, and significant financial burden to society. The goals of current treatments, such as cholinesterase inhibitors and N-methyl-D-aspartate receptor antagonist, are to reduce the severity or slow the progression of cognitive symptoms. Although these treatments have demonstrated modest clinical benefit, they are unable to prevent, prohibit, or reverse the underlying pathophysiology of AD. Considerable progress has been made toward the development of disease-modifying treatments. Treatments currently under development mainly target the production, aggregation, and removal of existing amyloid beta-peptide aggregates which are believed to instigate the overall development of the neuropathology. Additional strategies that target tau pathology are being studied to promote neural protection against AD pathology. The current research has continued to expand our knowledge toward the development of disease modifying Alzheimer's therapies; however, no specific treatment strategy capable of demonstrating empirical efficacy and safety has yet to emerge.

Pregnancy and delivery while receiving vagus nerve stimulation for the treatment of major depression: a case report.

BACKGROUND: Depression during pregnancy can have significant health consequences for the mother and her infant. Antidepressant medications, which pass through the placenta, may increase the risk of low birth weight and preterm delivery. The use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy may induce serotonergic symptoms in the infant after delivery. Antidepressant medications in breast milk may also be passed to an infant. Vagus nerve stimulation (VNS) therapy is an effective non-pharmacologic treatment for treatment-resistant depression (TRD), but little information exists regarding the use of VNS therapy during pregnancy. CASE PRESENTATION: The patient began receiving VNS therapy for TRD in March 1999. The therapy was effective, producing substantial reductions in depressive symptoms and improvement of function. In 2002, the patient reported that she was pregnant. She continued receiving VNS therapy throughout her pregnancy, labor, and delivery, which enabled the sustained remission of her depression. The pregnancy was uneventful; a healthy daughter was delivered at full term. CONCLUSION: In this case, VNS therapy provided effective treatment for TRD during pregnancy and delivery. VNS was safe for the patient and her child.