- Definitions of treatment-resistant depression
- Pseudoresistance in treatment-resistant depression
- (STAR*D) study
- When to switch or augment antidepressants
- Evidence base for augmentation strategies
- How long should augmentation therapy be continued in MDD after remission.
- When to use MAOIs
An audio interview that discusses pharmacological management of treatment-resistant depression with Dr. Prakash Masand, a Consulting Professor of Psychiatry and Behavioral Sciences at Duke University Medical Center.
Looking for a timely resource for psychopharmacology news and updates?
MPR (Monthly Prescribing Reference) has got you covered.
>> Check it out HERE
From the mind of Dr. Stephen Stahl and The Neuroscience Education Institute...
Federal law requires that a 72-hour emergency supply of a prescribed drug be provided when a medication is needed without delay and prior authorization (PA) is not available. This rule applies to non-preferred drugs on the Preferred Drug List and any drug that is affected by a clinical or therapeutic PA edit and would need prescriber prior approval.
One of my favorite tools is a guide/grid I made with all of the medications offered at a discount from the various pharmacies. Commonly known as the $4 programs.
I use this guide on a daily basis to try and get the best med for my uninsured clients at the best price. They appreciate it and I know it will help compliance. So here it is... I try and update it monthly.
An interesting concept...
From the website:
Moral Reconation Therapy (MRT) is a cognitive-behavioral counseling program that combines education, group and individual counseling, and structured exercises designed to foster moral development in treatment-resistant clients. Developed in 1985 by Gregory Little, Ed.D., and Kenneth Robinson, Ed.D., more than 120 published reports have documented that MRT-treated offenders show significantly lower recidivism for periods as long as 20 years after treatment. Studies show MRT-treated offenders have rearrest and reincarcertion rates 25% to 75% lower than expected.
More information at:
This is definitely a population I have difficulty working with. Usually when building a rapport is difficult, I'll try and walk in the client's shoes to gain perspective. This ends up being a more intellectual exercise than an emotional one though. I'll stitch together the likely emotional impact of their life events resulting in the current situation to foster empathy in myself. Which is all well and good, until they start asking me to prescribe marijuana... again. I go through the list of reasons I won't/can't, not the least of which is that it is illegal and not indicated for mental health issues in NH.
The above therapy sounds interesting but involved. I wonder how much of it could be used in a 20 minute med session. I once was introduced to Screening, Brief Intervention and Referral to Treatment (SBIRT) in Massachusetts. (http://www.mass.gov/eohhs/gov/departments/dph/programs/substance-abuse/prevention/screening-brief-intervention-and-referral-to.html). I've used the principles/techniques numerous times in my work to good effect.
But often, I'm at a loss and fall back on 'scaring them with science', aka using studies and facts about the negative effects of cannabis use. I know this can push clients away and make me sound like I am lecturing, so I usually soften the presentation with humor.
Anyone have a tips?
Often, I find myself torn between the art and the science of pharmacology - that ambiguous divide between clinical trials and (my somewhat limited) relevant clinical experience. One word that will conjure this dilemma every time is benzodiazepines.
Love them? Hate them? I like to think I walk the middle-ground, keeping the peace between the need for a fast-acting anxiolytic and a "happy pill". If so, then why do I still worry that I am being played every time I prescribe something ending in -azepam?
At first, I had the idea that I could have the decision be relative to each client. To hold my individualized care flag high and pat myself on the back for being less jaded than others in the field I had met. Maybe that would work... if I had more experience at reading people quickly or was a human lie detector. But once on my own with no Yoda-like preceptor to guide my way, things quickly became clouded. I've learned that meeting someone for the first time for forty minutes doesn't give you any deep insights, just a glimpse at past patterns.
So, a 55 year-old male with a h/o MDD, GAD, PTSD and ETOH dependence walks into... your office and wants to go back to drinking because his panic attacks and PTSD symptoms have gotten to be too much and the medications you have him on (AD plus non-benzo add-ons, likely some Naltrexone on the side) and his therapy just aren't cutting it. What do you do? Maybe he was using ETOH to self-medicate his anxiety? But then again, perhaps he is only now feeling his 'true' feelings and he can start the 'real' therapy work?
There is no easy answer. So, what I've done for now is to come up with a formula. Well, honestly its what I always do when I don't know the solution. I have my own set of rules I follow to figure out if benzos are even an option. After explaining how therapy, especially CBT is great for anxiety, I come at it two ways: (1) Long-term anxiety management - some kind of SSRI usually and (2) Short-term panic/anxiety management. The short term fix is a non-benzo to start, varying depending on their symptoms/meds/health conditions/etc... options include but aren't limited to hydroxyzine, clonidine, or gabapentin. This gets me by, but its no cure-all to the benzo dilemma.
If I decide to start someone on a benzo, it is to cover them while the LT anxiolytic takes effect and I am very clear about this (I even have it in writing). I tell them the plan is to keep them on the lowest therapeutic dose of a benzo as needed for 6-8 weeks and then taper them off and see what the LT med is doing for them. Also, that they should fully expect to feel some anxiety and that we are aiming for manageable levels not a cure. I (and evidence-based practice) are huge fans of therapy for anxiety remission and management.
I'm sure as my green wears off and I get wiser, I will look back on this post and shake my head at my over-simplification of it all. But, faced with a daunting number of decisions in a day, I need some way to narrow down my choices and let me sleep at night without worrying that I've become the next 'candy lady'.
This is one of two prescribing guides that I'm working on at the moment. I wanted to create an all-in-one symptom-based guide giving both indications and side effects. When I'm choosing a medication, I try use its whole profile, maybe ending up with some 'happy side effects'. A commonly used example being Remeron for depression and insomnia. This is sourced mainly from Stahl's, but I've also used a few other tidbit charts I've picked up along the way comparing medications within a single class.
I'd love to know what you all think! Do research results play out in clinical reality?