Other Therapeutic Options

Combination of medications and psychotherapy

There are very few clinical trials to guide with a specific selection of the optimal combination of antidepressants and psychotherapy. The same considerations in selecting monotherapy of antidepressants or psychotherapy apply. Monitoring with the same frequency for side effects, efficacy, adherence, and safety are the same in combination as when either therapy is given alone. If after 4 – 8 weeks there is not a moderate improvement in baseline symptoms, then a reassessment of the diagnosis, medication regimen, adherence, substance or alcohol use is in order. Change in treatment can be considered. If 4 – 8 weeks after the change in treatment there is not a moderate improvement in symptoms, another review should occur. Other treatment options should be considered in consultation with a psychiatric specialist if the patient fails to respond.

Electroconvulsive therapy (ECT)

ECT is exclusively available through an experienced psychiatric specialist. Remission rates with ECT are around 60 – 80 percent in severe major depressive disorder (UK ECT Review Group, Lancet 2003), and the maximum response is usually 3 weeks after treatment. ECT is the first line treatment when there is severe depression with psychotic features, psychomotor retardation, or resistance to medications. Suicidal patients and pregnant patients may also have rapid benefits from ECT. ECT consists of 6 – 12 treatments (2 to 3 times a week). Because the relapse rate after ECT is more than 50 percent, most psychiatrist start prophylactic treatment with antidepressants and adjuvant medications such as lithium. Postictal confusion, retrograde and anterograde memory impairment usually improves in a few days.

St. John’s Wort

St. John's wort

Question 12:

A 35 year old male who is HIV positive, takes antiretroviral medications, and lives with severe major depression has achieved remission of his depression on his SSRI but complains of lack of sexual libido. He read some information about St. John’s wort and asks if it would be appropriate to treat his depression. Which one of the following statements is appropriate advice to this patient: (Choose the best answer.)

  1. St. John’s wort is more effective than placebo in patients with severe major depression.
  2. St. John’s wort is not effective for treatment of major depression.
  3. St. John’s wort is safe for use in people taking HIV antiretroviral medications.
  4. St. John’s wort is safe and effective in combination with SSRIs and TCAs.
  5. St. John’s wort is safe and effective in combination with MAOIs.
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The correct answer is b. St. John’s wort is a plant product commonly used to treat depression. Although two dozen trials have been conducted on the use of St. John’s wort in depression, most have had significant flaws in design and do not enable meaningful interpretation.  The results of a randomized, double-blind, placebo-controlled clinical trial conducted between November 1998 and January 2000 in 11 academic medical centers in the United States with 200 participants found that St. John’s wort was not effective in the treatment of major depression (Sources: Shelton RC, Keller M, Gelenberg A, et al. Effectiveness of St. John’s wort in major depression: a randomized controlled trial. JAMA. 2001 (15); 285: 1978-1986). Information on combination of St. John’s wort and SSRIs and TCAs is unknown. St. John’s wort and combination of MAOIs is contraindicated. (Working Group on Major Depressive Disorders. Practice Guidelines for the Treatment of Patients With Major Depressive Disorder. American Psychiatric Association. 2000. Washington D.C.) St. John’s wort is not a drug and thus is not regulated by the FDA, thus there is a lack of standardized preparations. Patients living with HIV / AIDS and on antiretroviral treatment should be made aware that St. John’s wort is contraindicated because it lowers the serum levels of their antiretroviral cocktail.

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