23 - Treatment resistant depression other reporte

Treatment-resistant depression – other reported treatments

Depression and anxiety disorders CHAPTER 3 Treatment-­resistant depression – other reported treatments A very wide range of treatments have been investigated as potential therapy for treatment-­resistant depression. Table 3.5 briefly describes strategies that have limited support for their use but may be worth trying in exceptional circumstances. Prescribers should familiarise themselves with the primary literature before using these strategies. Table 3.5  Other reported treatments (alphabetical order – no preference implied). Treatment* Comments Ayahuasca1 Effective but specialist use only Buprenorphine2 0.8–2mg/day? Reasonable evidence but obvious contraindications Dexamethasone3,4 3–4 mg/day Limited data Dextromethorphan + quinidine5–7 45/10mg twice a day Promising novel treatment. NMDA antagonist. Quinidine is needed as CYP2D6 inhibitor to prolong action of dextromethorphan8 Folate/methyl folate9 Possible benefit Hyoscine10,11 (scopolomine) (4mcg/kg IV) Growing evidence base of prompt and sizeable effect MAOI and TCA12–14 e.g. trimipramine and phenelzine Formerly very widely used, but great care needed Minocycline 200mg/day Several positive meta-­analyses in both animals15 and humans.16,17 Recent failed RCTs.18,19 Modafinil20 100–400mg/day See section on stimulants in depression (this chapter) Naltrexone21,22 100mg/day No studies in non-­opiate misusers Nitrous oxide23–25 Short-­lived effect Nortriptyline ± lithium26–29 Re-­emergent treatment option Oestrogens30 (various regimens) Limited data Omega–3-­triglycerides EPA31–33 Many failed trials. Therapeutic dose not defined. Pindolol34–39 5mg three times a day or 7.5mg once daily Well tolerated, can be initiated in primary care. Data mainly relate to acceleration of response. Refractory data somewhat contradictory. Pramipexole40 0.125–5mg/day Probably effective Psilocybin41 10/25mg 1 week apart Effective but specialist use only Risperidone42 0.5–3mg/day to antidepressant Good RCT support as add-­on treatment S-­adenosyl-­l-­methionine43–45 400mg/day IM; 1600mg/day oral Limited data in treatment-­resistant depression. Use weakly supported by a Cochrane review.46 (Continued)