September 30, 2023 • 16 mins
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When the algorithm for treating depression begin to have more branch point than words hinting at what to do next, we'll come to your aid with this podcast. Tune in as we briefly review the treatments reserved for the refractive cases.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Amayo (00:00):
So we are assuming, you've done, you've done your
(00:02):
due diligence, you've checkedout.
Are you guys having a socialhour in here that I wasn't
invited to?
Because all I hear is himgiggling from down the hallway.
Welcome.
So today we have a special guestDr.
Sweet baby cheese.
I'm trying to do scholarlyactivity at the end of the
hallway.
We are too, three jokers arejust laughing hysterically in
(00:23):
the background.
Thanh (00:27):
Welcome to the Y in Psychiatry!
Dr. Amayo (00:29):
Hi, this is Dr.
Amayo C/L fellow.
Thanh (00:32):
Where we delve into the intricate nuances of psychiatric
topics.
Dr. Handratta (00:35):
My name is Dr.
Handratta attendingpsychiatrist.
I did my residency fromUniversity of Connecticut and
then I did my fellowship fromGeorgetown University in
consultation and liaison.
Thanh (00:45):
Each episode features interview style discussions that
explore the intersection of themind medicine and the human
experience.
Together we'll uncover thehidden why and the
groundbreaking discovery shapingthe psychiatric landscape.
So grab a seat, warm beverage,tune in, and let's embark on
this journey to unlock themysteries of the human psyche.
(01:09):
Only on The Y in Psychiatry.
Dr. Amayo (01:12):
Welcome back to the Y in psychiatry today.
I think today, so after we'vetalked about all the side
effects of SSRIs and SNRI,today, we are going down one
more level on that step ofalgorithm, how to treat
depression.
And before I continue to tellyou guys about that, I'm your
host, Dr.
(01:33):
Amayo Psychiatry,consult/liaison fellow.
And with me as usual is Dr.
Dr. Handratta (01:37):
Hi, I'm Dr.
Handratta.
How are you guys doing?
Dr. Amayo (01:40):
They're doing well.
I hope.
If not, stop listening and call9 1 1.
And so we talked about the firststep, right?
The first step.
Actually I'll say first step is,rule out medical causes.
Make sure you have the rightdiagnosis, that it's not bipolar
disorder.
See if you can do somebehavioral modifications and
(02:00):
some psychotherapy.
So you've done all that and thenyou, the next step, you start a
SSRI or SNRI, depending on thepatient factors.
If you dunno what I'm talkingabout, go back a few episodes
and you've done all that.
And Say, I have a patient thatI've exhausted all my SSRI
capabilities, and yet they'restill having symptoms of
depression.
Yeah.
PHQ9 is still a seven and itcame 98.
(02:24):
I'm not getting good response.
What should I do next?
Dr. Handratta (02:27):
Okay, so the next is if you want to be as happy
as, uh, Miracle, get some sleepdeprivation.
Miracle just came back fromTexas.
He hasn't slept, but he got hislicense.
Hi.
Congratulations.
Congratulations.
Yeah.
Yeah.
So let's go to Y in psychiatry.
So if you fail the first step,right?
(02:47):
So then you go to step two inthe algorithm.
So step two is if you, basicallythe step one has been
ineffective or you're not ableto tolerate the medication from
step one, right?
So step one, we talked aboutSSRI, we talked about SNRI.
We talked about bupropion, wetalked about mirtazapine and
vortioxetine as well asvilazodone.
(03:08):
So suppose that you tried allthese things you're not able to
tolerate or the ineffective goto step two, but before going to
step two, always make sure thatthe patient is adherent to the
treatment, right?
So compliance is very important.
We have problem in withcompliance in psychiatry.
We have problems with compliancein any field of medicine.
Especially if you go to adiabetic clinic or in
(03:29):
hypertension clinic is the samething, right?
So always good to ask thepatient, Hey, in a week how many
times or in a month, how manytimes have you forgotten to take
the medication?
That's a appropriate question toask the patient.
So they will tell one or twodays, right?
Make sure that they're adherentto the treatment.
The second thing that you needto actually make sure is that
you have used the medication ata therapeutic dosage for a
(03:52):
therapeutic period of time,right?
But if you do not give like anadequate dosage trial and
adequate duration trial, thenthe medication will be
ineffective, right?
The third thing is that makesure that your diagnosis is
correct, right?
Dr.
Amayo already spoke about makesure that you've ruled out
bipolar disorder and other.
Comorbid psychiatric disorder.
(04:15):
Then what we do is that if thepatient has shown a partial
response to the treatment not afull response, then we go with
something called augmentation.
So one of the augmentationstrategies at psychotherapy,
right?
Like cognitive, behavioraltherapy or interpersonal
therapy.
The second thing is, what youcan do is you can actually
augment with F D A approvedatypical antipsychotics.
(04:40):
So few of the F D A approvedatypical antipsychotics is
adding aripiprazole orbrexpiprazole or cariprazine or
quetiapine.
We won't be actually talkingabout quetiapine in step two.
We'll talk about it in stepthree because quetiapine is
associated with metabolic sideeffects.
Then if this is not work, thenyou basically augment the
(05:00):
antidepressants with s ketamineintranasal spray.
Or intravenous ketamine.
Intravenous Ketamine is not FDAapproved for depression, but
esketamine is right.
And the next strategy will be ifthey don't respond to es
Ketamine or iv Ketamine iscombination of antidepressants.
So you can combine an SSRI withbupropion or you can combine an
(05:23):
SNRI with mirtazapine.
And the combination of SNRI withmirtazapine works very well in
patients who have depressionwith anxious features.
But please do not combine SSRIwith SSRI or SNRI with SSRI or
SNRI with SNRI because the riskof serotonin syndrome.
Dr. Amayo (05:41):
And SSRI with Trazodone as well is okay.
Dr. Handratta (05:43):
It is okay.
Actually, SSRI with Trazodone,because the dosage of Trazodone
that we use is very low, and yourequire at least like 70 to 80%
blockage of the serotonintransporter to have the
antidepressant effect ofTrazodone.
So your dosage has to be likeabove a hundred and.
15 milligrams.
Yeah.
Dr. Amayo (06:01):
And so the next step in our algorithm for man
management of depression, add apsychotherapy or you can add a
antipsychotic.
And it sounds like these threeare the f D A approved ones with
less risk.
So aripiprazole, brexpiprazole,and cariprazine.
These are the D2 partial agonistmedications.
(06:24):
And then esketamine andketamine.
We talked about ketamine in oneof our other episodes.
And then you can, do somecombination of a SSRI or an SNRI
with another medication with adifferent form, right?
So that doesn't work.
What next do we do?
Dr. Handratta (06:38):
So if that does not work, Then you go with step
three.
Step three, right Now, stepthree basically means that now
this is a patient who may not bemanaged, who cannot be managed
in a primary care clinic, right?
Because most of the psychiatricpatients, they see the primary
care physicians actually fordepression, right?
We get like a small subset ofthose patients actually, who are
(07:00):
not able to be treated with theprimary care, come to
psychiatry.
Wait, are you saying even atstep two, a PCM, a primary care,
physician can prescribe anantipsychotic.
Yes, they can.
That's why actually we havesomething called collaborative
care clinic.
So now psychiatry is actuallygoing towards collaborative
(07:20):
care.
So the collaborative clinic is aprimary care clinic where you
have a social worker or a nursewho is basically embedded in the
clinic.
So the primary care providerwill see a case and they do a
PHQ9 or a GAD7, or they do aPHQ2 or GAD2 and it comes
positive.
They refer the patient to seethe case manager who's a social
(07:43):
worker or a nurse.
They will do psychiatricinterview and at the end of the
week, they'll call thepsychiatrist.
Discuss all the case.
The psychiatrist will look atthe medical, record, the labs,
and look at the scales, and thenwe'll come up with a treatment.
And the treatment is thenactually sent in a format to the
(08:03):
primary care provider whoimplements and writes a
prescription.
And then the case manager orcare manager will follow up the
patient.
And this is collaborative careclinic.
That's cool.
So majority of the patients canbe managed in a primary care
clinic.
Yeah.
Dr. Amayo (08:16):
Except when you get to step three.
Dr. Handratta (08:18):
Exactly.
So step three is basically meansthat these patients have tried
step one, tried step two, andthey're still not responding to
the treatment, or they've showna partial response, right?
Then you go to step three.
So step three, you have toactually get the psychiatrist
inward, right?
If the psychiatrist is notalready involved.
Dun.
Yes, exactly.
(08:39):
Again, the same thing, right?
You have to actually make surethat you have used a therapeutic
dosage.
For a therapeutic period oftime, you have to make sure that
the patient is adhere, adherentto the treatment.
Make sure that you have notmissed any medical problems
which is causing the underlyingdepression or any other
comorbidities, right?
And then you basically, if youhave ruled all those things out,
(09:01):
then again you actually useother augmentation strategies.
So in this augmentationstrategy, combine an
antidepressant with quetiapineand Tappin is used in step three
because of the metabolic sideeffects.
And then we will talk aboutactually, what are the things or
the tests to be ordered actuallywhen you prescribe an atypical
antipsychotic.
Next season.
(09:21):
Yeah.
Next season we'll do that.
And then if this does not work,then you combine the
antidepressants with lithium.
Lithium, or with T3, which isalso called cytomel.
Because T three actuallypenetrates the blood-brain
barrier better than T4.
T four.
So we use T3.
The game plan here is actuallyto start T3, get a baseline
(09:43):
before you start the T3.
Get a baseline free T3 and TSHlevel.
Dr. Amayo (09:47):
So just to clarify, T3 thyroid hormone.
Dr. Handratta (09:50):
Yes.
It's a thyroid hormone
Dr. Amayo (09:52):
But now levothyroxine medication.
Dr. Handratta (09:54):
So it is not levothyroxine.
Dr. Amayo (09:55):
So it's levothyroxine is T4 it's, yeah.
So the T3?
Yes.
Oh wow.
So it basically crosses theblood brain barrier.
It crosses.
Dr. Handratta (10:02):
So that's what you need.
And T3 augmentation works verywell, especially in female
population who have atypicaldepression.
That's a population that willrespond to T3.
So the game plan is when youstart T3 your game plan is to
have the free T3 at the upperlevel of normal.
Okay.
And your T4 at the lower levelof normal.
Without any.
(10:23):
Side effects.
Side effects, like the patientshould not actually have
arrhythmias.
And also make sure that youcheck the bone mineral density.
What if their T s H is already.
So what if the Ts H is alreadyvery low?
So the baseline T3 or T4 isalready maybe closer to the
upper level of normal.
Would you still do T3 then?
(10:45):
You will not.
You will not.
'cause you do not want it toactually cross the threshold.
Okay.
Okay.
So the Tsh it depends on thelab.
It's actually 0.45 and low.
Then I will not do it.
Okay.
Yeah.
Then basically we'll go withother strategy.
Okay.
So the other strategy iscombining the antidepressant
with I do not know how well thisworks, but it's actually in the
(11:05):
algorithm.
So with L-methyl folate or Sami?
Asil methionine.
Now you have to understand thatlevel one treatment, as placebo
controlled trials, randomizedcontrolled trials.
So the level one we talked abouthas a lot of strong data.
Level two also has data, but notas strong as level one.
Level one, and level three isusually like case control
studies.
(11:26):
So they're not Right.
So you're
Dr. Amayo (11:27):
Taking cowboy grain of salt.
Dr. Handratta (11:29):
Exactly.
Exactly.
So I don't want people toactually like, just prescribe.
So, I want people to supposethat the combination of L-methyl
folate or SAM-E does not workwith the 90%.
Dr. Amayo (11:40):
Do we know why, what the theoretical we basically
know actually that L-methylfolate and SAM-E basically works
on your methionine cycle.
So if you have a deficiency of,say, an enzyme actually in your
folate cycle.
Yeah.
Then you can actually use thisparticular treatment, or they
(12:03):
have a polymorphism in theenzyme, which is called as
methyl tetra hydro folatereductase.
Then this particular treatmentmay or may not work.
The data is not too strong.
But these are treatmentresistant cases.
Would you get a genetic testbefore you do it?
Because I know there's asubpopulation that has that
deficiency and they have atendency towards depression and
(12:25):
mood disorders.
So would you get a genetic testbefore you do it?
Dr. Handratta (12:29):
Yes, I usually get a genetic testing done.
Okay.
And if I see that there's apolymorphism in the methyl
folate reductase, then I'll addL-methyl folate to the
combination.
Okay.
Yes.
Right now, suppose that thisaugmentation strategy does not
work, then you combine theantidepressant that is SSRI or
SNRI, right?
With ECT, we can useelectroconvulsive treatment.
(12:52):
The response rate is very high.
We all know that ECT shouldactually be in level one, right?
Dr. Amayo (12:57):
In some cases.
Dr. Handratta (12:58):
Exactly, but we don't do that actually because
of the cognitive side effectsand the stigma that is
associated with ECT, but it'sone of the most effective
treatment for treatment.
Anti depression, right?
Or you basically can use rTMStrans magnetic stimulation,
right?
Where you focus on the leftdorsal, lateral prefrontal
cortex, or basically you switchfrom an SSRI or SNRI to
(13:19):
monoamine oxidase inhibitor.
Oh, which a lot of psychiatristsare scared to touch, right?
Or you switch them to tricyclicantidepressants.
Which we don't use it thatoften.
Neurologists use it for insomniaor for chronic pain, So this is
the treatment strategy in levelthree.
Level three.
Dr. Amayo (13:38):
And just to make sure we all get it, so you trial
first with quetiapine, if thatdoesn't work, lithium try T3
depending on their thyroidhormone levels methylfolate and
SAM in some certain populations.
ECT is always an option in anyof the steps.
TMS as well.
And then you start to think ofmono oxidase inhibitors.
(14:00):
And then if that doesn't work,call your local priest and
Craig.
No.
Dr. Handratta (14:06):
So step four is basically like you do three,
have not actually toleratedlevel three, or you have
developed side effects with themedications in level three.
Then you actually go with stepfour.
Dr. Amayo (14:18):
So if you trial that and you call your local priest
and that didn't help, then yougo with step four.
What do you do with step four?
So step four is threeantidepressant combination,
right?
So none of the data, again, isnot very strong.
These are case reports.
These are not randomizedcontrolled trial.
I want the one people to knowabout it.
So if everything has failed andthe patient is not, Mable for E
(14:42):
C T or R T M S, either becauseit's not available or it's too
expensive, right?
They cannot actually dointravenous ketamine because the
insurance doesn't cover it.
Or s Ketamine because theinsurance doesn't cover it.
So then, or it's too expensive,you only insurance covers.
Then you go with step four.
So step four is a three drugcombination, right?
(15:02):
So it's basically combining anSSRI or SNRI with Mirtazapine
and bupropion.
Or combining an SSRI or SNRIwith mirtazepine and lithium, or
combining SSRI or SNRI withbupropion plus atypical
(15:23):
antipsychotic.
And if this does not work, thenyou can use vagal nerve
stimulation.
That's another option that youhave which is going to be an
invasive procedure.
But that should actually be thelast option if nothing else.
Helps the patient.
So SSRI, N D R I and theatypical antipsychotic.
Dr. Handratta (15:43):
Yes.
Yeah.
Yes.
So that's all actually regardingthe treatment algorithm for
major depressive disorder.
Dr. Amayo (15:51):
And that's all we have in today's Why in
Psychiatry.
Dr. Handratta (15:56):
Happy Friday, guys.
Happy Friday.
Katrina (16:03):
Thank you for joining us on today's episode.
Our tireless team is alreadyhard at work, cobbling together
another potpourri of fascinatingdiscussion for next week, so be
sure to tune in, visit ourwebsite and our podcast feed and
let us know your thoughts on theepisode.
Subscribe so you don't miss ourreleases every Wednesday.
Until next time, keep smiling,keep shining, and stay curious.
So we are assuming, you've done, you've done your
(00:02):
due diligence, you've checkedout.
Are you guys having a socialhour in here that I wasn't
invited to?
Because all I hear is himgiggling from down the hallway.
Welcome.
So today we have a special guestDr.
Sweet baby cheese.
I'm trying to do scholarlyactivity at the end of the
hallway.
We are too, three jokers arejust laughing hysterically in
(00:23):
the background.
Thanh (00:27):
Welcome to the Y in Psychiatry!
Dr. Amayo (00:29):
Hi, this is Dr.
Amayo C/L fellow.
Thanh (00:32):
Where we delve into the intricate nuances of psychiatric
topics.
Dr. Handratta (00:35):
My name is Dr.
Handratta attendingpsychiatrist.
I did my residency fromUniversity of Connecticut and
then I did my fellowship fromGeorgetown University in
consultation and liaison.
Thanh (00:45):
Each episode features interview style discussions that
explore the intersection of themind medicine and the human
experience.
Together we'll uncover thehidden why and the
groundbreaking discovery shapingthe psychiatric landscape.
So grab a seat, warm beverage,tune in, and let's embark on
this journey to unlock themysteries of the human psyche.
(01:09):
Only on The Y in Psychiatry.
Dr. Amayo (01:12):
Welcome back to the Y in psychiatry today.
I think today, so after we'vetalked about all the side
effects of SSRIs and SNRI,today, we are going down one
more level on that step ofalgorithm, how to treat
depression.
And before I continue to tellyou guys about that, I'm your
host, Dr.
(01:33):
Amayo Psychiatry,consult/liaison fellow.
And with me as usual is Dr.
Dr. Handratta (01:37):
Hi, I'm Dr.
Handratta.
How are you guys doing?
Dr. Amayo (01:40):
They're doing well.
I hope.
If not, stop listening and call9 1 1.
And so we talked about the firststep, right?
The first step.
Actually I'll say first step is,rule out medical causes.
Make sure you have the rightdiagnosis, that it's not bipolar
disorder.
See if you can do somebehavioral modifications and
(02:00):
some psychotherapy.
So you've done all that and thenyou, the next step, you start a
SSRI or SNRI, depending on thepatient factors.
If you dunno what I'm talkingabout, go back a few episodes
and you've done all that.
And Say, I have a patient thatI've exhausted all my SSRI
capabilities, and yet they'restill having symptoms of
depression.
Yeah.
PHQ9 is still a seven and itcame 98.
(02:24):
I'm not getting good response.
What should I do next?
Dr. Handratta (02:27):
Okay, so the next is if you want to be as happy
as, uh, Miracle, get some sleepdeprivation.
Miracle just came back fromTexas.
He hasn't slept, but he got hislicense.
Hi.
Congratulations.
Congratulations.
Yeah.
Yeah.
So let's go to Y in psychiatry.
So if you fail the first step,right?
(02:47):
So then you go to step two inthe algorithm.
So step two is if you, basicallythe step one has been
ineffective or you're not ableto tolerate the medication from
step one, right?
So step one, we talked aboutSSRI, we talked about SNRI.
We talked about bupropion, wetalked about mirtazapine and
vortioxetine as well asvilazodone.
(03:08):
So suppose that you tried allthese things you're not able to
tolerate or the ineffective goto step two, but before going to
step two, always make sure thatthe patient is adherent to the
treatment, right?
So compliance is very important.
We have problem in withcompliance in psychiatry.
We have problems with compliancein any field of medicine.
Especially if you go to adiabetic clinic or in
(03:29):
hypertension clinic is the samething, right?
So always good to ask thepatient, Hey, in a week how many
times or in a month, how manytimes have you forgotten to take
the medication?
That's a appropriate question toask the patient.
So they will tell one or twodays, right?
Make sure that they're adherentto the treatment.
The second thing that you needto actually make sure is that
you have used the medication ata therapeutic dosage for a
(03:52):
therapeutic period of time,right?
But if you do not give like anadequate dosage trial and
adequate duration trial, thenthe medication will be
ineffective, right?
The third thing is that makesure that your diagnosis is
correct, right?
Dr.
Amayo already spoke about makesure that you've ruled out
bipolar disorder and other.
Comorbid psychiatric disorder.
(04:15):
Then what we do is that if thepatient has shown a partial
response to the treatment not afull response, then we go with
something called augmentation.
So one of the augmentationstrategies at psychotherapy,
right?
Like cognitive, behavioraltherapy or interpersonal
therapy.
The second thing is, what youcan do is you can actually
augment with F D A approvedatypical antipsychotics.
(04:40):
So few of the F D A approvedatypical antipsychotics is
adding aripiprazole orbrexpiprazole or cariprazine or
quetiapine.
We won't be actually talkingabout quetiapine in step two.
We'll talk about it in stepthree because quetiapine is
associated with metabolic sideeffects.
Then if this is not work, thenyou basically augment the
(05:00):
antidepressants with s ketamineintranasal spray.
Or intravenous ketamine.
Intravenous Ketamine is not FDAapproved for depression, but
esketamine is right.
And the next strategy will be ifthey don't respond to es
Ketamine or iv Ketamine iscombination of antidepressants.
So you can combine an SSRI withbupropion or you can combine an
(05:23):
SNRI with mirtazapine.
And the combination of SNRI withmirtazapine works very well in
patients who have depressionwith anxious features.
But please do not combine SSRIwith SSRI or SNRI with SSRI or
SNRI with SNRI because the riskof serotonin syndrome.
Dr. Amayo (05:41):
And SSRI with Trazodone as well is okay.
Dr. Handratta (05:43):
It is okay.
Actually, SSRI with Trazodone,because the dosage of Trazodone
that we use is very low, and yourequire at least like 70 to 80%
blockage of the serotonintransporter to have the
antidepressant effect ofTrazodone.
So your dosage has to be likeabove a hundred and.
15 milligrams.
Yeah.
Dr. Amayo (06:01):
And so the next step in our algorithm for man
management of depression, add apsychotherapy or you can add a
antipsychotic.
And it sounds like these threeare the f D A approved ones with
less risk.
So aripiprazole, brexpiprazole,and cariprazine.
These are the D2 partial agonistmedications.
(06:24):
And then esketamine andketamine.
We talked about ketamine in oneof our other episodes.
And then you can, do somecombination of a SSRI or an SNRI
with another medication with adifferent form, right?
So that doesn't work.
What next do we do?
Dr. Handratta (06:38):
So if that does not work, Then you go with step
three.
Step three, right Now, stepthree basically means that now
this is a patient who may not bemanaged, who cannot be managed
in a primary care clinic, right?
Because most of the psychiatricpatients, they see the primary
care physicians actually fordepression, right?
We get like a small subset ofthose patients actually, who are
(07:00):
not able to be treated with theprimary care, come to
psychiatry.
Wait, are you saying even atstep two, a PCM, a primary care,
physician can prescribe anantipsychotic.
Yes, they can.
That's why actually we havesomething called collaborative
care clinic.
So now psychiatry is actuallygoing towards collaborative
(07:20):
care.
So the collaborative clinic is aprimary care clinic where you
have a social worker or a nursewho is basically embedded in the
clinic.
So the primary care providerwill see a case and they do a
PHQ9 or a GAD7, or they do aPHQ2 or GAD2 and it comes
positive.
They refer the patient to seethe case manager who's a social
(07:43):
worker or a nurse.
They will do psychiatricinterview and at the end of the
week, they'll call thepsychiatrist.
Discuss all the case.
The psychiatrist will look atthe medical, record, the labs,
and look at the scales, and thenwe'll come up with a treatment.
And the treatment is thenactually sent in a format to the
(08:03):
primary care provider whoimplements and writes a
prescription.
And then the case manager orcare manager will follow up the
patient.
And this is collaborative careclinic.
That's cool.
So majority of the patients canbe managed in a primary care
clinic.
Yeah.
Dr. Amayo (08:16):
Except when you get to step three.
Dr. Handratta (08:18):
Exactly.
So step three is basically meansthat these patients have tried
step one, tried step two, andthey're still not responding to
the treatment, or they've showna partial response, right?
Then you go to step three.
So step three, you have toactually get the psychiatrist
inward, right?
If the psychiatrist is notalready involved.
Dun.
Yes, exactly.
(08:39):
Again, the same thing, right?
You have to actually make surethat you have used a therapeutic
dosage.
For a therapeutic period oftime, you have to make sure that
the patient is adhere, adherentto the treatment.
Make sure that you have notmissed any medical problems
which is causing the underlyingdepression or any other
comorbidities, right?
And then you basically, if youhave ruled all those things out,
(09:01):
then again you actually useother augmentation strategies.
So in this augmentationstrategy, combine an
antidepressant with quetiapineand Tappin is used in step three
because of the metabolic sideeffects.
And then we will talk aboutactually, what are the things or
the tests to be ordered actuallywhen you prescribe an atypical
antipsychotic.
Next season.
(09:21):
Yeah.
Next season we'll do that.
And then if this does not work,then you combine the
antidepressants with lithium.
Lithium, or with T3, which isalso called cytomel.
Because T three actuallypenetrates the blood-brain
barrier better than T4.
T four.
So we use T3.
The game plan here is actuallyto start T3, get a baseline
(09:43):
before you start the T3.
Get a baseline free T3 and TSHlevel.
Dr. Amayo (09:47):
So just to clarify, T3 thyroid hormone.
Dr. Handratta (09:50):
Yes.
It's a thyroid hormone
Dr. Amayo (09:52):
But now levothyroxine medication.
Dr. Handratta (09:54):
So it is not levothyroxine.
Dr. Amayo (09:55):
So it's levothyroxine is T4 it's, yeah.
So the T3?
Yes.
Oh wow.
So it basically crosses theblood brain barrier.
It crosses.
Dr. Handratta (10:02):
So that's what you need.
And T3 augmentation works verywell, especially in female
population who have atypicaldepression.
That's a population that willrespond to T3.
So the game plan is when youstart T3 your game plan is to
have the free T3 at the upperlevel of normal.
Okay.
And your T4 at the lower levelof normal.
Without any.
(10:23):
Side effects.
Side effects, like the patientshould not actually have
arrhythmias.
And also make sure that youcheck the bone mineral density.
What if their T s H is already.
So what if the Ts H is alreadyvery low?
So the baseline T3 or T4 isalready maybe closer to the
upper level of normal.
Would you still do T3 then?
(10:45):
You will not.
You will not.
'cause you do not want it toactually cross the threshold.
Okay.
Okay.
So the Tsh it depends on thelab.
It's actually 0.45 and low.
Then I will not do it.
Okay.
Yeah.
Then basically we'll go withother strategy.
Okay.
So the other strategy iscombining the antidepressant
with I do not know how well thisworks, but it's actually in the
(11:05):
algorithm.
So with L-methyl folate or Sami?
Asil methionine.
Now you have to understand thatlevel one treatment, as placebo
controlled trials, randomizedcontrolled trials.
So the level one we talked abouthas a lot of strong data.
Level two also has data, but notas strong as level one.
Level one, and level three isusually like case control
studies.
(11:26):
So they're not Right.
So you're
Dr. Amayo (11:27):
Taking cowboy grain of salt.
Dr. Handratta (11:29):
Exactly.
Exactly.
So I don't want people toactually like, just prescribe.
So, I want people to supposethat the combination of L-methyl
folate or SAM-E does not workwith the 90%.
Dr. Amayo (11:40):
Do we know why, what the theoretical we basically
know actually that L-methylfolate and SAM-E basically works
on your methionine cycle.
So if you have a deficiency of,say, an enzyme actually in your
folate cycle.
Yeah.
Then you can actually use thisparticular treatment, or they
(12:03):
have a polymorphism in theenzyme, which is called as
methyl tetra hydro folatereductase.
Then this particular treatmentmay or may not work.
The data is not too strong.
But these are treatmentresistant cases.
Would you get a genetic testbefore you do it?
Because I know there's asubpopulation that has that
deficiency and they have atendency towards depression and
(12:25):
mood disorders.
So would you get a genetic testbefore you do it?
Dr. Handratta (12:29):
Yes, I usually get a genetic testing done.
Okay.
And if I see that there's apolymorphism in the methyl
folate reductase, then I'll addL-methyl folate to the
combination.
Okay.
Yes.
Right now, suppose that thisaugmentation strategy does not
work, then you combine theantidepressant that is SSRI or
SNRI, right?
With ECT, we can useelectroconvulsive treatment.
(12:52):
The response rate is very high.
We all know that ECT shouldactually be in level one, right?
Dr. Amayo (12:57):
In some cases.
Dr. Handratta (12:58):
Exactly, but we don't do that actually because
of the cognitive side effectsand the stigma that is
associated with ECT, but it'sone of the most effective
treatment for treatment.
Anti depression, right?
Or you basically can use rTMStrans magnetic stimulation,
right?
Where you focus on the leftdorsal, lateral prefrontal
cortex, or basically you switchfrom an SSRI or SNRI to
(13:19):
monoamine oxidase inhibitor.
Oh, which a lot of psychiatristsare scared to touch, right?
Or you switch them to tricyclicantidepressants.
Which we don't use it thatoften.
Neurologists use it for insomniaor for chronic pain, So this is
the treatment strategy in levelthree.
Level three.
Dr. Amayo (13:38):
And just to make sure we all get it, so you trial
first with quetiapine, if thatdoesn't work, lithium try T3
depending on their thyroidhormone levels methylfolate and
SAM in some certain populations.
ECT is always an option in anyof the steps.
TMS as well.
And then you start to think ofmono oxidase inhibitors.
(14:00):
And then if that doesn't work,call your local priest and
Craig.
No.
Dr. Handratta (14:06):
So step four is basically like you do three,
have not actually toleratedlevel three, or you have
developed side effects with themedications in level three.
Then you actually go with stepfour.
Dr. Amayo (14:18):
So if you trial that and you call your local priest
and that didn't help, then yougo with step four.
What do you do with step four?
So step four is threeantidepressant combination,
right?
So none of the data, again, isnot very strong.
These are case reports.
These are not randomizedcontrolled trial.
I want the one people to knowabout it.
So if everything has failed andthe patient is not, Mable for E
(14:42):
C T or R T M S, either becauseit's not available or it's too
expensive, right?
They cannot actually dointravenous ketamine because the
insurance doesn't cover it.
Or s Ketamine because theinsurance doesn't cover it.
So then, or it's too expensive,you only insurance covers.
Then you go with step four.
So step four is a three drugcombination, right?
(15:02):
So it's basically combining anSSRI or SNRI with Mirtazapine
and bupropion.
Or combining an SSRI or SNRIwith mirtazepine and lithium, or
combining SSRI or SNRI withbupropion plus atypical
(15:23):
antipsychotic.
And if this does not work, thenyou can use vagal nerve
stimulation.
That's another option that youhave which is going to be an
invasive procedure.
But that should actually be thelast option if nothing else.
Helps the patient.
So SSRI, N D R I and theatypical antipsychotic.
Dr. Handratta (15:43):
Yes.
Yeah.
Yes.
So that's all actually regardingthe treatment algorithm for
major depressive disorder.
Dr. Amayo (15:51):
And that's all we have in today's Why in
Psychiatry.
Dr. Handratta (15:56):
Happy Friday, guys.
Happy Friday.
Katrina (16:03):
Thank you for joining us on today's episode.
Our tireless team is alreadyhard at work, cobbling together
another potpourri of fascinatingdiscussion for next week, so be
sure to tune in, visit ourwebsite and our podcast feed and
let us know your thoughts on theepisode.
Subscribe so you don't miss ourreleases every Wednesday.
Until next time, keep smiling,keep shining, and stay curious.
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