Posted by bleauberry on October 24, 2009, at 15:47:16
In reply to i'm disabled :;( trying to recover from all this :, posted by Jeroen on October 24, 2009, at 14:55:17
I spent about an hour studying at pubmed to hopefully find some useful stuff for you. Here is what I discovered so far:
1. Psychotic depression is understudied and difficult to treat, thus helping to explain the tough road you have been on.
2. There are many successful outcomes of previously impossible cases...NONE of them happened until an antidepressant was used...either imipramine, amitriptyline, luvox, effexor, or zoloft...sometimes monotherapy with the AD alone, and sometimes when combined with either Risperdal, Zyprexa, or Seroquel. This is potentially very cool, because it provides you with a toolbox of the very specific meds to focus on in various combinations to duplicate what they did in hospitals around the world with patients like you. The toolbox consists of Fluvoxamine, Sertraline, Imipramine, Amitriptyline, Risperidone, Olanzapine, Quetiapine, and possible addition of Lithium to any of the combinations.
3. ECT with meds is viewed as the best course...I disagree...but certainly worth keeping on the radar screen.
4. Of the SSRIs used successfully, Luvox and Zoloft appeared the best, as you'll see below, and the theory is that it has something to do with sigma receptors.
There are more studies than just the ones I copied below, but here are a few to read. You will see a few things you have already done, so those will be easy to rule out and focus on the other things you haven't done:
Psychotic depression is frequent among hospitalized patients diagnosed with major depression. Patients diagnosed with this type of depression display a number of specific characteristics. They have a higher risk of suicidal behaviour, they have a prolonged and more severe clinical picture and subsequently they have an increased risk of relapse. Studies show that monotherapy with antidepressants is more effective than antipsychotic monotherapy. Electroconvulsive therapy remains the most effective treatment, while tricyclic antidepressants in monotherapy are also effective. An antipsychotic drug can be added if no effect of monotherapeutic antidepressant treatment is observed within two to four weeks.
PMID: 19014722 [PubMed - indexed for MEDLINE]
Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA.This new version of the psychotic depression algorithm has been developed by the Psychopharmacology Algorithm Project at the Harvard South Shore Program. The most effective treatment modality for inpatients with severe psychotic depression is electroconvulsive therapy. The first-line psychopharmacological treatment is a combination of an antidepressant (either a tricyclic or a selective serotonin reuptake inhibitor) and an antipsychotic. If one of these combinations has failed, consider switching to the other. If both combinations have failed, the next psychopharmacological option would be to augment the combination with lithium. Another option, though with limited evidence, is monotherapy with clozapine. If there is a good reason to avoid combination therapy with an antipsychotic, then a trial of monotherapy with a TCA or an SSRI can be supported. If that fails, adding an antipsychotic or ECT should be considered.
PMID: 18661366 [PubMed - indexed for MEDLINE]
Neuroscience Education Institute, University of California-San Diego, San Diego, CA, USA.
Psychotic major depression is a severe condition that frequently proves difficult-to-treat. The most effective traditional treatments (electroconvulsive therapy and combinations of antipsychotics with tricyclic antidepressants) are associated with significant side effects, and the use of tricyclic antidepressants alone is largely ineffective. Recent evidence has indicated that the selective serotonin reuptake inhibitors, either alone or in combination with antipsychotics, may provide a desirable alternative to traditional treatments. Among selective serotonin reuptake inhibitors, fluvoxamine has been the best studied and, somewhat surprisingly, has proven effective in several studies as a monotherapy without the need to combine with an antipsychotic. It is proposed that the apparent efficacy of fluvoxamine in psychotic major depression may be related to its unique property of high affinity for the sigma 1 receptor, which is thought to play a role in psychosis and in the action of some antipsychotic drugs.
PMID: 15788959 [PubMed - indexed for MEDLINE]
Rudolf Magnus Institute of Neuroscience, Department of Psychiatry, University Medical Center Utrecht, Utrecht, the Netherlands.
Wijkstra J, Burger H, van den Broek WW, Birkenhäger TK, Janzing JGE, Boks MPM, Bruijn JA, van der Loos MLM, Breteler LMT, Ramaekers GMGI, Verkes RJ, Nolen WA. Treatment of unipolar psychotic depression: a randomized, double-blind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine.Objective: It remains unclear whether unipolar psychotic depression should be treated with an antidepressant and an antipsychotic or with an antidepressant alone. Method: In a multi-center RCT, 122 patients (18-65 years) with DSM-IV-TR psychotic major depression and HAM-D-17 >/= 18 were randomized to 7 weeks imipramine (plasma-levels 200-300 mug/l), venlafaxine (375 mg/day) or venlafaxine-quetiapine (375 mg/day, 600 mg/day). Primary outcome was response on HAM-D-17. Secondary outcomes were response on CGI and remission (HAM-D-17). Results: Venlafaxine-quetiapine was more effective than venlafaxine with no significant differences between venlafaxine-quetiapine and imipramine, or between imipramine and venlafaxine. Secondary outcomes followed the same pattern. Conclusion: That unipolar psychotic depression should be treated with a combination of an antidepressant and an antipsychotic and not with an antidepressant alone, can be considered evidence based with regard to venlafaxine-quetiapine vs. venlafaxine monotherapy. Whether this is also the case for imipramine monotherapy is likely, but cannot be concluded from the data.
PMID: 19694628 [PubMed - as supplied by publisher]
The purpose of the present study is to compare the efficacy of imipramine in the treatment of psychotic versus nonpsychotic depression. Previous studies report varying results of monotherapy with antidepressants in psychotic depression. Because psychotic depression is seriously underinvestigated, performing a post hoc analysis of randomized clinical trials consisting of both psychotic and nonpsychotic depressed patients may contribute to the discussion on the optimal treatment of depressed patients with mood-congruent psychotic features. A total of 112 patients diagnosed with major depression (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) (40 with psychotic depression and 82 without psychotic features) received treatment with imipramine for 6 weeks after a washout period of 7 days. Imipramine doses were adjusted to attain a predefined fixed plasma level. Treatment response was assessed with the Hamilton Rating Scale for Depression (HAM-D). A logistic regression analysis showed a significantly larger reduction in HAM-D score in the sample with psychotic features compared with the nonpsychotic sample (regression coefficient, -3.47; SE, 1.7; P = 0.04). According to the primary outcome criterion, that is, the change in HAM-D score, imipramine was significantly more effective in the sample with psychotic depression compared with the nonpsychotic depressed patients. The contradiction between our results and those of several previous studies may be due to the fixed plasma level dosing of imipramine refraining from concurrent psychotropic medication or limiting our patient sample to patients with mood-congruent psychotic features.
PMID: 18344726 [PubMed - indexed for MEDLINE]
poster:bleauberry
thread:922251
URL: http://www.dr-bob.org/babble/20091021/msgs/922261.html