uestion: Has the patient had an adequate trial of an
MAOI?uestion: Has the patient had an adequate trial of an
MAOI?
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Help: An adequate trial of phenelzine (Nardil) would be at least 60 mg for four weeks. In some cities, a platelet MAO level is available from certain laboratories and can be used to delineate an adequate trial: there should be at least a 70% drop in the platelet MAO level from the baseline level prior to treatment at two weeks. Tranylcypromine (Parnate) trials should be at 30-40 mg per day. No correlation with platelet MAO levels have been found.
Experience suggests that response or non-response to one MAOI does not predict whether the patient will respond to another MAOI. It is advisable to wait two weeks for washout when switching from one MAOI to another.
Go ahead with a trial of an MAOI. If a long washout period is required before the MAOI can be administered (e.g. at least five weeks if fluoxetine is a current treatment, with some advocating checking a blood level for presisting levels of norfluoxetine before starting the MAOI), bupropion might be offered first if it was not tried previously. Bupropion might also be an alternative if the rigors of an MAOI trial are judged too arduous for this patient. There is one published study where bupropion was quite effective compared with fluoxetine in atypical depression of criteria variant from the Columbia criteria.¹
If bupropion is used, keep in mind that bupropion is metabolized by Cytochrome IID6 and SSRI's may increase blood levels and the risk of seizures, though the risk of the latter is much less with bupropion SR.² Also, bupropion is contraindicated in patients with a history of bulimia or anorexia nervosa.
Another potentially useful option is phototherapy, which has been shown to be quite helpful in seasonal (winter) depressions with atypical symptoms, and might enable you to avoid having to use an MAOI.³ Seasonal patients with melancholic features did not do very well with phototherapy.³ An SSRI may be effective in seasonal depressions*, but that will have already been tried by this point in the algorithm.
Phenelzine is the best established MAOI for this indication.(4)
Recommendation #04
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¹Goodnick PJ, Extein H. Bupropion and fluoxetine in depressive subtypes. Ann Clin Psychiatry 1989; 1:119-122.
²Preskorn SH, Burke M. Somatic therapy for major depressive disorder; selection of an antidepressant. J Clin Psychiatry 1992; 53(suppl 9):5-18.
³Terman M et al. Predictors of response and nonresponse to light treatment for winter depression. Am J Psychiatry 1996;153:1423-1429.
*Lam RW et al. Multicenter, placebo-controlled study of fluoxetine in seasonal affective disorder. Am J Psychiatry 1995;152:1765-1770.
(4) Quitkin FM, Stewart JW, McGrath PJ, et al. Columbia atypical depression: a subgroup of depressives with better response to MAOI than to tricylic antidepressants or placebo. Br J Psychiatry 1993;163(suppl 21):30-34.
There have been two or three sequential adequate trials of antidepressants and yet the response remains unsatisfactory. Before proceeding with further trials, the clinician must again undertake a thorough review of medical, psychological, and environmental factors which could account for the unsatisfactory results so far. It would perhaps be worthwhile to check a plasma folate level, since that might be a factor contributing to the poor response, and give supplemental folate if it is low.¹ The diagnosis is reviewed again, and as part of that review a more formal assessment of comorbidity of Axes I and II should occur. This may assist with determining whether and what kind of additional pharmacotherapy trials would be worth pursuing.
As a starting point for this assessment, we divide depressed patients into melancholic (or mood non-reactive) depressions versus non-melancholic depressions again.. The reason is because of a study that showed that the presence of personality disorder accounted for a significant amount of the variance in long-term outcome of non-melancholic depressed patients, whereas personality disorder had no impact on outcome of melancholic depression.² Other lines of evidence indicate that "personality disorders" can sometimes respond rather specifically to pharmacotherapy.³
Therefore, for the non-melancholic pharmacotherapy-resistant depressions, specific Axis II diagnoses are closely evaluated at this point in the algorithm, to see if any of the proposed useful medications have not yet been tried. Then, for all pharmacotherapy resistant depressions (melancholics, and the rest of the non-melancholics after treatment of their Axis II diagnoses), a formal review of possible Axis I comorbidity is undertaken. This review will determine possible directions for the next somatic treatment options.
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¹Fava M, Borus JS, Alpert JE, Nierenberg AA, Rosenbaum JF, Bottiglieri T. Folate, vitamin B12, and homocysteine in major depressive disorder. American Journal of Psychiatry. 1997;154:426-428. ²Andrews G, Neilson M, Hunt C, Stewart G, Kiloh LG. Diagnosis, personality, and the long term outcome of depression. British Journal of Psychiatry. 1990;157:13-18. ³Fava M, Bouffides E, Pava J. Personality disorder comorbidity with major depression and response to fluoxetine treatment. Psychotherapy and Psychosomatics. 1994;62:160-167.
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uestion: Does the patient have Atypical depression?
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