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Treatment Length

Posted by SLS on December 20, 2022, at 7:10:26

For people who are being treated for their first episode of depression, psychiatrists have generally continued a successful treatment for their patients for 12-14 months beyond the point remission is achieved.

The guidelines for treating a case of depression that has a chronic or recurrent course are different from those used for treating a first episode. This is especially true when treating people who have demonstrated a history of being resistant or refractory to multiple courses of treatment. Under these circumstances, continuing treatment indefinitely is a reasonable choice. For most of the people who have been posting on Psycho-Babble for years and years, I dont see how indefinite treatment wouldnt make the most sense.

There are some new treatments being studied that might allow for short-term or intermittent dosing to prevent relapse. I think there is growing optimism that drugs with hallucinogenic properties might be able to be used as a single dose exposure. The optimum schedule for dosing intranasal ketamine is about once every 5 days.

One drug to keep an eye out for is zuranolone, which is an orally-administered analogue of the I.V. treatment using brexanolone for post-partum depression. Zuranolone has the potential to be dosed intermittently. Every time I read an article about zuranolone, the FDA is always just weeks away from approving it, so who knows. This has been going on for two years. There were a few problems with the first set of clinical trials, so Sage Pharmaceuticals had to perform three more. In the subsequent trials, Zuranolone performed better than placebo for the following conditions using *intermittent* dosing.

1. Major Depressive Disorder
2. Bipolar Depression
3. Post-Partum Depression

The Company also shared insights from the terminated RAINFOREST and REDWOOD Studies today. The RAINFOREST Study was designed to investigate the efficacy and safety of 30 mg zuranolone in comorbid MDD and insomnia. The REDWOOD Study was designed to study fixed schedule intermittent dosing of 30 mg zuranolone throughout the course of a year. Both studies were terminated in 2020 based on the Companys plans to advance the program with the 50 mg dose of zuranolone.

* Why would anyone risk the return of a paralyzing, severe depression that might become totally refractory to all of the remaining treatments? After spending years or decades searching for an effective treatment, does it make sense to discontinue it after only 12-14 months?

The following is representative of stories we have seen described on Psycho-Babble. One story resulted in suicide. I cant remember which drugs he was responding to, but it improvement wasnt happening quick enough for him. For people like me, it can take a year to reach full remission. Instead of electing to be patient and continuing treatment without deviation, he started playing around and eventually committed suicide. Would he have done this if he knew it can take as long as a year to reach full remission? Knowledge is power. I think he would still be with us.

Here is another tragic story:

I have seen this happen too many times in my life. A dear friend of mine finally found a treatment that worked for her after being treated with a smorgasbord of drugs and drug combinations. She also had two courses of ECT. Finally, one of her doctors decided to try lithium monotherapy on her. She responded and achieved remission. She remained well for 8 years until she took a traveling-nurse job on the west coast. Of course, she had to find a doctor there in order to continue getting prescriptions for her lithium. She found one. Unfortunately, it was the wrong one. By the end of her first meeting with him, he decided that she had been taking lithium long enough. So, he had her discontinue it. Her kidneys and thyroid were just fine.

Three months passed. Then, she relapsed. Gee. What do you think happened when her doctor had her restart lithium treatment? Well, it has been three decades, and she doesn't take lithium anymore. That's because it never worked again. Robert M. Post of the NIH had seen this happen a number of times in his department of biological psychiatry. He named this phenomenon "lithium-discontinuation induced lithium-refractoriness" in 1992. My friend was his research patient at the NIH at the time. When I met her, she was age 36. Her west-coast psychiatrist made his arrogant and tragic decision 8 years prior. She was 24 at the time. She is now 66. She would never again experience normal human consciousness.

Paxil (paroxetine) seems to be the SSRI most likely to demonstrate this phenomenon.

I cannot think of a single posting member of the Psycho-Babble community who should consider discontinuing a successful drug treatment after 12-14 months. It never once crossed my mind after 1990 that my miracle cure wouldnt include indefinite treatment. Given my history, discontinuing medication after only 2 years of a robust response would defy sanity.

Of course, side-effects and the possibility of long-term sequalae can complicate the decision-making process. Its your doctors job to describe the risks to you as well as the potential benefits of a given treatment.

For Gods sake, stop pulsing antidepressants on a whim.

Its not rocket surgery.

- Scott

Some see things as they are and ask why.
I dream of things that never were and ask why not.

The only thing necessary for the triumph of evil is that good men do nothing.




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