08. Major Depressive Disorder Algorithm: Was the Antidepressant Trial Adequate? (Node 4)

This is video 8 of the Algorithm for the Psychopharmacology of Major Depression from the Harvard South Shore Psychopharmacology Algorithm Project. We just completed in video 7 the algorithm for inpatients with severe melancholic depression. But if the patient is not an inpatient with severe melancholic depression, you arrive at this node which is node 4 as shown in the figure which I provided earlier. This is where the rest of the population of depressed patients can be found including all outpatients even if they have melancholia and other depressed inpatients without the melancholic specifier. And if none of the comorbidities and other circumstances that we described in video 3 and 4 apply, then we have this question to start out this video:

Have you given the patient our first-choice antidepressants for this basic major depression case? Have you given an adequate trial of one of three preferred antidepressants, sertraline, escitalopram or bupropion? Those are our first line. We prefer the escitalopram and sertraline over the other SSRIs but we have bupropion in there for patients who wish to avoid having the risk of sexual side effects because they can be extremely unpleasant. We need to warn people that 40% to 80% of patients will get them and that they usually, majority of the time they do not remit with time. We have treatments for them but if you don’t want to chance them and deal with them, we’ve got bupropion as an effective first-line option. Cipriani in her two meta-analyses showed that sertraline and escitalopram had slight advantages over the other antidepressants taking into account effectiveness. And cand tolerability. ost is also a consideration. There are a few that are pretty good but they’re much more costly so we don’t have them as first line.