Chapter 68: Major Depressive Disorder

Content Update

August 15, 2019

Brexanolone (Zulresso) for Treatment of Postpartum Depression in Adult Women: Brexanolone is a neuroactive steroid and GABA_A receptor modulator approved for treatment of postpartum depression in adult women. Results of one phase II and two phase III randomized, double-blind, placebo-controlled clinical trials provide evidence for the efficacy and safety of brexanolone compared to placebo as evidenced by reduction in HAM-D scores. Brexanolone carries a black box warning for excessive sedation and sudden loss of consciousness and is only available via REMS program restriction. The treatment requires a 60-hour continuous intravenous infusion that is expected to cost $34,000; these factors will limit brexanolone use to a select population of women with postpartum depression.

Content Update

June 1, 2019

Newly Approved Medications for treatment-resistant depression in conjunction with an oral antidepressant: The U.S. Food and Drug Administration (FDA) approved intranasal esketamine (Spravato^®) for adults who have demonstrated resistance (failed at least two previous trials of adequate dose and duration) to other therapies for major depressive disorder. Intranasal esketamine plus a newly initiated oral antidepressant demonstrated superiority over intranasal placebo and oral antidepressant in reducing symptoms of depression as measured by the Montgomery-Asberg Depression Rating Scale (MADRS).

Content Update

April 28, 2018

Use of Ketamine for Improving Suicidal Ideation: Ketamine is an emerging agent for the rapid treatment of depression. None of the other available antidepressants are effective for rapid relief of suicidal thoughts in patients with depression. Results from a randomized clinical trial suggest that adjunctive use of ketamine was more effective than midazolam in reducing clinically significant suicidal ideation.

Content Update

September 16, 2017

Antidepressant Switching vs Augmentation on Remission Among Major Depressive Disorder Patients: Many patients with major depressive disorder (MDD) do not achieve remission with their first course of antidepressant pharmacotherapy, and some may benefit from an alternative treatment. A clinical trial compared the effectiveness and adverse effect profiles of three alternative treatment strategies: 1) switching to bupropion sustained-release monotherapy; 2) augment current treatment with bupropion sustained-release; or 3) augment current treatment with aripiprazole. Augmentation with aripiprazole resulted in a slight but statistically significant increased likelihood of remission during 12 weeks of treatment compared to switching to bupropion monotherapy. Further study is needed to evaluate the long-term risk-benefit ratio of this treatment strategy.

KEY CONCEPTS

• Extensive treatment guidelines are available to assist in the treatment of major depressive disorder, including medication management. Clinicians treating individuals with major depressive disorder should be familiar with these guidelines.

• When evaluating a patient for the presence of depression, it is essential to rule out medical causes of depression and drug-induced depression.

• The goals ...