Pharmacological strategies in treatment-resistant depression.

Treatment-resistant depression may be due to factors such as co-morbid psychiatric or medical illnesses, chronic psychosocial stresses, and medication nonadherence. Alternative treatment strategies such as optimization, switching to a different antidepressant, augmentation or combination with another antidepressant are strategies useful in such patients. The first strategy in treating resistant depression is to optimize monotherapy. A switch should be made to another agent if there is no response to treatment after an adequate duration. Augmentation and combination strategies are useful if there is sub-optimal response to the initial antidepressant. With several antidepressants (selective serotonin reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors and the newer antidepresssants) and various antidepressant augmentation and combination strategies available to clinicians, the outcome of treating patients with depression should improve.

Adverse neuropsychiatric reactions to herbal and over-the-counter "antidepressants".

BACKGROUND: Many unregulated over-the-counter agents for the treatment of depression are now available to patients and consumers. The potential for adverse neuropsychiatric effects with these agents has not been systematically studied in most cases. DATA SOURCES: The author performed a MEDLINE search on a variety of herbal and nonherbal over-the-counter agents said to be useful in the treatment of depression. The Physicians' Desk Reference for Herbal Medicines was also consulted. DATA SYNTHESIS: Although many of the herbal agents said to have benefits in depression appear to be safe, serious neuropsychiatric side effects and interactions have been reported for several over-the-counter "antidepressants." There is reason to suspect underreporting of those adverse events. Moreover, there is very little evidence from systematic studies regarding the potential for drug-drug or herb-drug interactions with these over-the-counter agents. Vitamins and amino acids touted for the treatment of depression are also not without risk. CONCLUSION: Although some over-the-counter remedies for depression are probably safe and effective for as-yet unidentified subgroups of depressed individuals, more research is required before these agents can be recommended for routine use. Stricter U.S. Food and Drug Administration oversight of these agents is indicated.

Mastering the cytochromes: a practical primer.

The author reviews the basic properties of the cytochrome enzyme systems and discusses why it is important for prescribing psychiatrists to be familiar with them. He then reviews the specific properties and types of interactions associated with the cytochrome families that play the most important roles in psychotropic drug metabolism: CYP 3A4, CYP 2D6, CYP 1A2, and CYP 2C. Tables are provided listing the principle substrates, inhibitors, and inducers of each of these cytochrome families. Finally, practical and clinical considerations in assessing the potential for cytochrome interactions are reviewed and illustrated with clinical vignettes.

The diagnosis and treatment of subclinical hypothyroid states in depressed patients.

The diagnosis and treatment of subclinical hypothyroidism in mood-disordered patients is complex and somewhat controversial. The psychiatrist must recognize that such subclinical states may contribute to depression, mood cycling, or delayed response to treatment if undetected. Autoimmune thyroiditis, which may ultimately lead to various grades of hypothyroidism, may also be seen in depressed populations, particularly in postpartum females. The author discusses these issues by means of a clinical vignette, then proposes an algorithm for the diagnosis and treatment of hypothyroid states in mood disordered populations.

Self-injurious behavior: pathophysiology and implications for treatment.

BACKGROUND: Self-injurious behavior (SIB) is a common clinical problem that affects a diverse group of patients and populations. Little is known about the underlying pathophysiology and pharmacologic treatment of SIB. METHOD: The authors selectively reviewed the clinical literature on SIB and related aggressive/impulsive behaviors, with the aim of formulating provisional guidelines for pharmacotherapy. RESULTS: The serotonergic system is most directly implicated in the pathophysiology of SIB and related behaviors. While there is no well-established "drug of choice" for SIB, the identification of specific subgroups of SIB patients and associated symptoms such as psychosis permits the rational selection of medication. Serotonin selective reuptake inhibitors, other serotonergic agents, antipsychotics, beta-blockers, and opiate antagonists all play a role in the treatment of SIB. CONCLUSION: SIB is not a single entity and may have different pharmacologic treatments, depending on the associated symptoms and target population. Medications that act on the serotonergic system appear to be the most promising.

Differential diagnosis and treatment of steroid-induced affective syndromes.

The differential diagnosis of hypercortisolemia is complex, particularly when the clinician must distinguish Cushing's syndrome (CS) from major depression. The present clinical case history demonstrates that by means of physical and laboratory examinations, the psychiatrist can make the initial differentiation, in consultation with medical specialists. The use of the corticotropin-releasing factor (CRF) stimulation test may be especially helpful in distinguishing Cushing's disease (CD) from major depression, though there is some degree of "overlap" in results. This suggests that these disorders may lie along a continuum of hypothalamopituitary dysfunction.