The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An Update on Unipolar Nonpsychotic Depression

[Pathogenetic basis of modern approaches to the therapy of sleep disorders in the clinic of depression]

Epidemiological studies indicate that about 35% of the world's population periodically suffer from insomnia. Many authors in their studies note sleep disturbances in the clinic of both somatic and mental disorders, often considering sleep disturbances as one of the predictors of these diseases. In psychiatric practice, sleep disorders are most often described in the clinic of depression, which is determined by the general pathophysiological mechanisms of their development due to disruption of the activity of the main neurotransmitter systems of the brain. The results of clinical studies show that the drug of choice in the treatment of sleep disorders in the depression clinic is the antidepressant Mirtazapine, which has a unique profile of pharmacological activity. According to international recommendations, Mirtazapine is a first-line drug in the treatment of anxiety and depressive disorders with sleep disorders and sexual dysfunction caused by taking other antidepressants.

[Recent approaches to the diagnosis and therapy of monopolar depression]

Unipolar depression is one of the most significant biomedical problems, which is associated with its high prevalence, a pronounced negative impact on the level of work capacity of the population, worsening of the course of most somatic and neurological diseases, and suicide risk. This review presents current data on approaches to the diagnosis of monopolar depression, both classical (clinical and psychometric) and using modern technologies. The existing approaches to the therapy of monopolar depression - psychopharmacologic, psychotherapeutic, and non-drug biological approaches - are discussed. The advantages of the selective serotonin reuptake inhibitor sertraline are presented, and its use as a first-line drug is justified.

Intersection of Sex and Depression: Pathogenesis, Presentation, and Treatments

Major Depressive Disorder (MDD) is a highly prevalent, debilitating disorder. According to the World Health Organization, approximately 5% of adults suffer from depression worldwide and more women than men are affected. Yet, we have a very limited understanding of the pathogenesis of the disease, how sex and genetics influence the pathophenotype of MDD, and how they contribute to the responses to pharmacological treatment. This chapter addresses key theories about the etiology of depression, the variations in epidemiology and presentation, and the treatment options with respect to sex and gender. Additionally, we discuss the emerging wave of treatment modalities, diagnosis, and research focusing on MDD.

An evidence-based approach to psychopharmacology for posttraumatic stress disorder (PTSD) - 2022 update

Algorithms for posttraumatic stress disorder were published by this team in 1999 and 2011. Developments since then warrant revision. New studies and review articles from January 2011 to November 2021 were identified via PubMed and analyzed for evidence supporting changes. Following consideration of variations required by special patient populations, treatment of sleep impairments remains as the first recommended step. Nightmares and non-nightmare disturbed awakenings are best addressed with the anti-adrenergic agent prazosin, with doxazosin and clonidine as alternatives. First choices for difficulty initiating sleep include hydroxyzine and trazodone. If significant non-sleep PTSD symptoms remain, an SSRI should be tried, followed by a second SSRI or venlafaxine as a third step. Second generation antipsychotics can be considered, particularly for SSRI augmentation when PTSD-associated psychotic symptoms are present, with the caveat that positive evidence is limited and side effects are considerable. Anti-adrenergic agents can also be considered for general PTSD symptoms if not already tried, though evidence for daytime use lags that available for sleep. Regarding other pharmacological and procedural options, e.g., transcranial magnetic stimulation, cannabinoids, ketamine, psychedelics, and stellate ganglion block, evidence does not yet support firm inclusion in the algorithm. An interactive version of this work can be found at www.psychopharm.mobi.

Care Management of Comorbid Medical and Psychiatric Illness: A Conceptual Framework for Improving Equity of Care

Psychiatric and medical comorbidities are common among adults in the United States. Due to the complex interplay between medical and psychiatric illness, comorbidities result in substantial disparities in morbidity, mortality, and health care costs. There is, thus, both an ethical and fiscal imperative to develop care management programs to address the needs of individuals with comorbid conditions. Although there is substantial evidence supporting the use of care management for improving health outcomes for patients with chronic diseases, the majority of interventions described in the literature are condition-specific. Given the prevalence of comorbidities, the authors of this article reviewed the literature and drew on their clinical expertise to guide the development of future multimorbidity care management programs. Their review yielded one study of multimorbidity care management and two studies of multimorbidity collaborative care. The authors supplemented their findings by describing three key pillars of effective care management, as well as specific interventions to offer patients based on their psychiatric diagnoses and illness severity. The authors proposed short-, medium-, and long-term indicators to measure and track the impact of care management programs on disparities in care. Future studies are needed to identify which elements of existing multimorbidity collaborative care models are active ingredients, as well as which of the suggested supplemental interventions offer the greatest value.

Quality of clinical practice guidelines for inadequate response to first-line treatment for depression according to AGREE II checklist and comparison of recommendations: a systematic review

OBJECTIVE

To assess similarities and differences in the recommended sequence of strategies among the most relevant clinical practice guidelines (CPGs) for the treatment of depression in adults with inadequate response to first-line treatment.

DATA SOURCES

We performed a systematic review of the literature spanning January 2011 to August 2020 in Medline, Embase, Cochrane Library and 12 databases recognised as CPGs repositories. CPGs quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II).

STUDY SELECTION

The eligibility criteria were CPGs that described pharmacological recommendations for treating depression for individuals aged 18 years or older in outpatient care setting. We included CPGs considered of high-quality (≥80% in domain 3 of AGREE II) or recognised as clinically relevant.

DATA EXTRACTION

Two independent researchers extracted recommendations for patients who did not respond to first-line pharmacological treatment from the selected CPGs.

RESULTS

We included 46 CPGs and selected 8, of which 5 were considered high quality (≥80% in domain 3 of AGREE II) and 3 were recognised as clinically relevant. Three CPGs did not define inadequate response to treatment and 3 did not establish a clear sequence of strategies. The duration of treatment needed to determine that a patient had not responded was not explicit in 3 CPGs and was discordant in 5 CPGs. Most CPGs agree in reassessing the diagnosis, assessing the presence of comorbidities, adherence to treatment, and increase dosage as first steps. All CPGs recommend psychotherapy, switching antidepressants, and considering augmentation/combining antidepressants.

CONCLUSION

Relevant CPGs present shortcomings in recommendations for non-responders to first-line antidepressant treatment including absence and divergencies in definition of inadequate response and sequence of recommended strategies. Overall, most relevant CPGs recommend reassessing the diagnosis, evaluate comorbidities, adherence to treatment, increase dosage of antidepressants, and psychotherapy as first steps.

PROSPERO REGISTRATION NUMBER

CRD42016043364.

Treatment-Resistant Depression: Approaches to Treatment

Approximately 30% of people treated for a major depressive episode will not achieve remission after two or more treatment trials of first-line antidepressants and are considered to have treatment-resistant depression (TRD). Because the odds of remission decrease with every subsequent medication trial, it is important for clinicians to understand the characteristics and risk factors for TRD, subtypes of major depressive disorder that are more likely to be less responsive to first-line anti-depressants, and the available treatment options. In the current article, we review the approved treatments for TRD, including esketamine, and the evidence for psilocybin and pramipexole. Although limited in specificity, guidelines to help prescribers identify person-centered treatments for TRD are available. [Journal of Psychosocial Nursing and Mental Health Services, 59(9), 7-11.].

Experimental Therapeutics in Treatment-Resistant Major Depressive Disorder

Treatment-Resistant Depression (TRD) patients remain a challenging sub-division of patients with Major Depressive Disorder (MDD) in day to day clinical practice. As with any diagnostic condition, comprehensive evaluation, exclusion of other psychiatric conditions, assessment of co-morbid medical and psychiatric illnesses and psychosocial stressors are the keys to appropriate diagnosis and subsequent management. There are various management options available for the treatment of MDD, however, about 30% of the patients fail to achieve full remission of symptoms despite multiple trials and belong to this sub-category of MDD. This article brings forth discussion of other non-conventional medication and non-medication treatment alternatives that merit exploration of their efficacy in TRD. Many of the proposed novel medications and other treatment modalities such as Deep Brain Stimulation, exercise, yoga are already used for other medical and psychiatric disorders and have some evidence suggesting their potential benefits in TRD in conjunction with conventional medications or even as monotherapy. Nevertheless, more research is needed in this direction to establish effectiveness.

The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An update on management of behavioral and psychological symptoms in dementia

Geriatric patients with dementia frequently present with agitation, aggression, psychosis, and other behavioral and psychological symptoms of dementia (BPSD). We present an update of our previously published algorithms for the use of psychopharmacologic agents in these patients taking into account more recent studies and findings in meta-analyses, reviews, and other published algorithms. We propose three algorithms: BPSD in an emergent, urgent, and non-urgent setting. In the emergent setting when intramuscular (IM) administration is necessary, the first-line recommendation is for olanzapine (since IM aripiprazole, previously favored, is no longer available) and haloperidol injection is the second choice, followed by possible consideration of an IM benzodiazepine. In the urgent setting, the first line would be oral second-generation antipsychotics (SGAs) aripiprazole and risperidone. Perhaps next could be then prazosin, and lastly electroconvulsive therapy is a consideration. There are risks associated with these agents, and adverse effects can be severe. Dosing strategies, discontinuation considerations, and side effects are discussed. In the non-emergent setting, medications are proposed for use in the following order: trazodone, donepezil and memantine, antidepressants such as escitalopram and sertraline, SGAs, prazosin, and carbamazepine. Other options with less support but potential future promise are discussed.

The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An update on bipolar depression

BACKGROUND

The Psychopharmacology Algorithm Project at the Harvard South Shore Program (PAPHSS) published algorithms for bipolar depression in 1999 and 2010. Developments over the past 9 years suggest that another update is needed.

METHODS

The 2010 algorithm and associated references were reevaluated. A literature search was conducted on PubMed for recent studies and review articles to see what changes in the recommendations were justified. Exceptions to the main algorithm for special patient populations, including those with attention-deficit hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), substance use disorders, anxiety disorders, and women of childbearing potential, and those with common medical comorbidities were considered.

RESULTS

Electroconvulsive therapy (ECT) is still the first-line option for patients in need of urgent treatment. Five medications are recommended for early usage in acute bipolar depression, singly or in combinations when monotherapy fails, the order to be determined by considerations such as side effect vulnerability and patient preference. The five are lamotrigine, lurasidone, lithium, quetiapine, and cariprazine. After trials of these, possible options include antidepressants (bupropion and selective serotonin reuptake inhibitors are preferred) or valproate (very small evidence-base). In bipolar II depression, the support for antidepressants is a little stronger but depression with mixed features and rapid cycling would usually lead to further postponement of antidepressants. Olanzapine+fluoxetine, though Food and Drug Administration (FDA) approved for bipolar depression, is not considered until beyond this point, due to metabolic side effects. The algorithm concludes with a table of other possible treatments that have some evidence.

CONCLUSIONS

This revision incorporates the latest FDA-approved treatments (lurasidone and cariprazine) and important new studies and organizes the evidence systematically.

The psychopharmacology algorithm project at the Harvard South Shore Program: An algorithm for core symptoms of autism spectrum disorder in adults

Autism spectrum disorder (ASD) is characterized by impaired social communication and restricted repetitive behaviors and interests. There are no FDA-approved medications for these core symptoms, and there are limited data regarding pharmacological management of ASD in adults. Here, the literature was reviewed in an effort to develop an algorithm for pharmacological management of core symptoms of ASD in adults. The literature search was conducted using PubMed. It was very difficult to distil a plausible algorithm from these data. Not included in this review are behavioral strategies, which are first-line. For instances when medication is being considered for management of core ASD symptoms in adults, the authors suggest starting with fluvoxamine as first-line, with possible consideration of a second SSRI trial if there is an inadequate or no response to fluvoxamine. The next step, if there is comorbid irritability, is to consider a second-generation antipsychotic. If there is no comorbid irritability, in the final step of the tentative algorithm, there are possible augmenting agents: propranolol, memantine, d-cycloserine, and oxytocin. Management of the symptoms of ASD requires a comprehensive treatment approach, and treatment planning must be individualized. Treatment of core ASD symptoms is not always desired. Further studies are needed to develop a stronger evidence base to support pharmacological management of core symptoms.

The psychopharmacology algorithm project at the Harvard South Shore Program: An algorithm for adults with obsessive-compulsive disorder

A previous algorithm for the pharmacological treatment of obsessive-compulsive disorder was published in 2012. Developments over the past 7 years suggest an update is needed. The authors conducted searches in PubMed, focusing on new studies and reviews since 2012 that would support or change previous recommendations. We identified exceptions to the main algorithm, including pregnant women and women of child-bearing potential, the elderly, and patients with common medical and psychiatric co-morbidities. Selective serotonin reuptake inhibitors (SSRIs) are still first-line. An adequate trial requires a period at typical antidepressant doses and dose adjustments guided by a plasma level to evaluate for poor adherence or ultra-rapid metabolism. If the response is inadequate, consider a trial of another SSRI this time possibly taken to a very high dose. Clomipramine could be an alternative. If the response to the second trial remains inadequate, the next recommendation is to augment with aripiprazole or risperidone. Alternatively, augmentation with novel agents could be selected, including glutamatergic (memantine, riluzole, topiramate, n-acetylcysteine, lamotrigine), serotonergic (ondansetron), and anti-inflammatory (minocycline, celecoxib) agents. A third option could be transcranial magnetic stimulation. Lastly, after several of these trials, deep brain stimulation and cingulotomy have evidence for a role in the most treatment-refractory patients.