1. Medication Strategies: Switch vs. Augmentation Robert K. Schneider, MD Assistant Professor Departments of Psychiatry, Internal Medicine and Family Practice Virginia Commonwealth University The Medical College of Virginia Campus

2. Outline Review “Pseudoresistance” Before Treatment Class Choice Switching vs Augmentation

3. Decreased state due to up- regulation of receptors Neurotransmitter Receptor Hypothesis of Antidepressant Action 6-2 Stahl S M, Essential Psychopharmacology (2000)

4. 6-3 6-4 Stahl S M, Essential Psychopharmacology (2000) MAO inhibitor tells the enzyme to stop destroying NT Neurotransmitter Receptor Hypothesis of Antidepressant Action Increase in NT causes receptors to down-regulate

5. 6-5 6-6 Stahl S M, Essential Psychopharmacology (2000) Antidepressant blocks the reuptake pump, causing more NT to be in the synapse Neurotransmitter Receptor Hypothesis of Antidepressant Action Increase in NT causes receptors to down-regulate

6. receptor sensitivity 6-1 Stahl S M, Essential Psychopharmacology (2000) amount of NT clinical effect antidepressant introduced

7. “Pseudoresistance” Dose too low Duration too short Wrong medication –Class –Augmentation

8. “Pseudoresistance” Wrong diagnosis –Psychiatric –Medical –Comorbid diagnoses (Medical and Psychiatric)

9. Before treatment Target symptoms Education Expectation Stressors Patient preference Psychotherapy

10. Choice of class Which neuortransmitters (5HT, NE, DA) Diagnosis Target symptoms Side effects Previous medication trials –Understand reason for “failure” Combined vs. monotherapy

11. Classes/Types SSRIs Venlafaxime Nafazodone Buproprion TCADs Mirtazepine

12. Dosing “Start low and go slow” Severity of symptoms “Angle of decent” Previous dosage levels

13. Switch vs. Augmentation Multiple class failures Class specific side effects Patient preference Response vs. remission

14. 5-4 Stahl S M, Essential Psychopharmacology (2000) acute 6 - 12 weeks continuation 4-9 months maintenance 1 or more years TIME DEPRESSION NORMAL MOOD RELAPSE RECURRENCE

15. Augmentation SSRI + Trazodone –PTSD –GAD –Target sleep Middle insomnia Nightmares

16. Augmentation SSRI + Benzodiazepine –Anxiety disorders Especially Panic and GAD –Initial insomnia

17. Augmentation SSRI + buproprion –Response but still fatigued or decreased concentration –Response but smoking still –History of ADD or ADHD

18. Augmentation SSRI + TCAD –Response and poor sleep –Response and pain –Response and male or postmenopausal

19. Augmentation Stimulants –Response and decreased concentration or fatigue –“Organic” etiologies –Side effects at higher doses

20. CASES