Section - Video Lectures

10. Node 7: Antidepressant Monotherapy

Published on September 1, 2021 Expired on April 1, 2024

David Osser, M.D.

Associate Professor of Psychiatry - Harvard Medical School

Key Points

All antipsychotics may have significant side effects.
There is support for antidepressant monotherapy, but the data are flawed.
Fluvoxamine, sertraline, and venlafaxine may be considered the best antidepressants.
There are risks of psychotic exacerbation with antidepressant monotherapy.
TCA monotherapy may work better than SSRIs, but the risk of psychosis may increase.
If there is no response, reconsider adding an antipsychotic.

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Slides and Transcript

Slide 1 of 17

Hello. This is Dr. David Osser and I am presenting video number 10 of our series on an algorithm for the treatment of psychotic depression with somatic and pharmacotherapy approaches, major depression with psychotic features in the DSM-5. And we have spent the first 9 videos going over the most recommended treatments, which start with ECT, and then proceed to combinations of antipsychotics and antidepressants. And there are various combinations that are preferred for various reasons that we've delineated for you. We've also talked about a couple of augmentation strategies with medication, with lithium and even with methylphenidate and what the evidence is on those.

Node 7: Antidepressant Monotherapy Slide 1 of 17

Slide 2 of 17

So, in this video number 10, we are going to discuss back to antidepressant monotherapy because there are some situations where you may want to avoid an antipsychotic. After all, antipsychotics can all cause tardive dyskinesia. Even the second-generation ones have rates of approximately 1% which can rise to maybe 5% in the elderly over the course of a year. So, there may be reasons to see if you could get somewhere with an antidepressant alone. Most guidelines recommend starting with a combination like we do. But should you decide to do that, what would you pick as your antidepressant?

References:

Tang M, Osser DN. (2012). The Psychopharmacology Algorithm Project at the Harvard South Shore Program: 2012 update on psychotic depression. Journal of Mood Disorders, 2(4),167-179.
Hamoda, H. M., & Osser, D. N. (2008). The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An update on psychotic depression. Harvard Review of Psychiatry, 16(4), 235-247.

Node 7: Antidepressant Monotherapy Slide 2 of 17

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11. Take-Home Messages