Medication Strategies: Switch vs. Augmentation

1
Medication StrategiesSwitch 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
Neurotransmitter Receptor Hypothesis of
Antidepressant Action
Decreased state due to up-regulation of receptors
4
Neurotransmitter Receptor Hypothesis of
Antidepressant Action
MAO inhibitor tells the enzyme to stop destroying
NT
Increase in NT causes receptors to down-regulate
5
Neurotransmitter Receptor Hypothesis of
Antidepressant Action
Antidepressant blocks the reuptake pump, causing
more NT to be in the synapse
Increase in NT causes receptors to down-regulate
6
(No Transcript)
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
acute 6 - 12 weeks
continuation 4-9 months
maintenance 1 or more years
TIME
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