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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by nephron on May 2, 2004, at 7:15:57
My pdoc says that there's an evidence-based systematic method of treating depression pharmalogically (to complement therapy stuff)...
SSRIs- so Paxil or Cipralex or what have you- try 2 or 3- if these don't work move to
SNRIs- for example Effexor, then
Tricyclics: for example impiramine, then
Selective reversible MAOIs- e.g. moclobemide.
If none of these work well enough, pick the one which worked best with the least side effects, and add a mood stabiliser like lithium.
Any feedback on this?
Thanks, Sarah
Posted by SLS on May 2, 2004, at 10:04:02
In reply to Depression systematic treatment, posted by nephron on May 2, 2004, at 7:15:57
> Selective reversible MAOIs- e.g. moclobemide.Hi Sarah.
I don't think moclobemide should be the last in the series of things to try before moving on retrials of previously inadequate drugs + mood stabilizers. I'm not sure moclobemide should be there at all, actually. It does not have a good track record, and has gone into disuse in many parts of the world. In its place, I would recommend instead the irreversible MAOIs like Parnate and Nardil. Their effectiveness in otherwise treatment-resistant patients is well established.
- Scott
Posted by Sad Panda on May 2, 2004, at 14:14:36
In reply to Depression systematic treatment, posted by nephron on May 2, 2004, at 7:15:57
> My pdoc says that there's an evidence-based systematic method of treating depression pharmalogically (to complement therapy stuff)...
>
> SSRIs- so Paxil or Cipralex or what have you- try 2 or 3- if these don't work move to
>
> SNRIs- for example Effexor, then
>
> Tricyclics: for example impiramine, then
>
> Selective reversible MAOIs- e.g. moclobemide.
>
> If none of these work well enough, pick the one which worked best with the least side effects, and add a mood stabiliser like lithium.
>
> Any feedback on this?
>
> Thanks, Sarah
>
>Hi Sarah,
> SSRIs- so Paxil or Cipralex or what have you- try 2 or 3- if these don't work move
>Paxil is the last of the SSRI's to try due to it having the worst side effects & being difficult to withdrawl from. Zoloft is a good first try because it's the safest & has the best track record of the SSRI's, Lexapro seems like it's worth a go too as it seems to be gathering postive users. Prozac is worth a go because it's easy to give up.
> SNRIs- for example Effexor, then
>Effexor dragged me out of a deep hole, so I am fond of it.
> Tricyclics: for example impiramine, then
>Not Imipramine. Clomipramine & Amitriptyline are the two TCA's with the best record, side effects probably aren't much worse than SSRI's, just different. Nortriptyline & Desipramine have their uses too, they can add energy to an SSRI that is working & they are usefull to some ADD people like Strattera is.
> Selective reversible MAOIs- e.g. moclobemide.
>I agree with Scott 110%. Moclobemide is pretty useless for the majority of people, but maybe the thing for someone who has tried everything else.
Similar are Wellbutrin, Remeron & Trazodone, they are pretty weak for most people, but can be a great add on to SSRI's or Effexor as something that counters side effects, i.e. Wellbutrin can rid people of SSRI induced apathy or increase libido. I take Remeron with Effexor & have found it gives great sleep as well as rids me of nausea and anorgasmia problems caused by Effexor.
The irreversible MAOI's Nardil & Parnate are possibly the best AD's that feature the least side effects, but you have to watch what you eat & what drugs you take with them. Sadly these two seem to be the last resort, even though they could be possibly first choice. Given a choice, I would cut to the chase & go directly to Parnate for my symptoms knowing what I know now.
Cheers,
Panda.
Posted by Keith Talent on May 3, 2004, at 6:41:47
In reply to Re: Depression systematic treatment » nephron, posted by Sad Panda on May 2, 2004, at 14:14:36
Sarah and others, you may not be aware, but there is a big trial called Star*D going on now, which will provide some rational, evidence-based algorithms for treatment of major depressive episodes. I found out by chance by viewing some of the streaming video psychiatry grand rounds from the University of Chicago (where Dr Bob is). One of the principal investigators is Dr Andrew Nierenberg of Harvard. Perhaps an insider could further enlighten us?
Posted by nephron on May 3, 2004, at 8:29:32
In reply to Re: Depression systematic treatment, posted by Keith Talent on May 3, 2004, at 6:41:47
That's fantastic- if only I were privy to all the study results and able to prescribe :P
I have someone who I believe is bright and a good psychiatrist now, but he charges exhorbitant rates. Not an issue for me, but I have friends who are relying on public health care (Australia) and the shitty psychs that work in it :( I figure I'd make a better psych than most of them.
~Sarah
Posted by Emme on May 3, 2004, at 10:13:31
In reply to Depression systematic treatment, posted by nephron on May 2, 2004, at 7:15:57
Hmmmm...maybe I'm off base on this, but I can't help but feel skeptical about the whole concept of a treatment algorithm. Obviously doctors will have preferences about which drugs they like to use first. But with so many individual differences, variability in symptoms, etc., I wonder if a cookie cutter approach is the best way to treat mood and anxiety disorders. Maybe it's a good first start but one needs to get more creative after a few failed trials. Perhaps I'll ask my pdoc how she goes about deciding what to prescribe.
Posted by Emme on May 3, 2004, at 10:14:23
In reply to Depression systematic treatment, posted by nephron on May 2, 2004, at 7:15:57
I'd definitely not consider Wellbutrin or Remeron to be weak ADs.
Posted by Keith Talent on May 3, 2004, at 22:43:54
In reply to Re: Depression systematic treatment, posted by Emme on May 3, 2004, at 10:13:31
All the trial is attempting to do is inject some rationality and rigour into the way that depressive episodes are treated. Psychiatric drug trials have had a reputation for being extremely underpowered and underfunded compared to internal medicine drug trials. Hopefully, this one will redress some of that. I can't imagine the researchers are trying to foist a cookie-cutter approach on the psychiatrists of this world - I sure hope not.
Posted by harryp on May 4, 2004, at 4:53:41
In reply to Re: Depression systematic treatment, posted by SLS on May 2, 2004, at 10:04:02
I second that. Reversible/selective MAOI's are a nice idea, but they don't appear to be very good AD's.
>
> > Selective reversible MAOIs- e.g. moclobemide.
>
> Hi Sarah.
>
> I don't think moclobemide should be the last in the series of things to try before moving on retrials of previously inadequate drugs + mood stabilizers. I'm not sure moclobemide should be there at all, actually. It does not have a good track record, and has gone into disuse in many parts of the world. In its place, I would recommend instead the irreversible MAOIs like Parnate and Nardil. Their effectiveness in otherwise treatment-resistant patients is well established.
>
>
> - Scott
>
>
This is the end of the thread.
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