Algorithm Based Treatment of Unipolar Major Depression in Outpatients: Role of TriiodothyronineAGID, O; LERER, B.Biological Psychiatry Unit, Department of Psychiatry, Hadassah-Hebrew University Medical Center, Ein Karem,, Jerusalem 91120, Israel. Clinicians who treat major depression are faced with a bewildering choice of antidepressant drugs. Given that all treatments have a lag period before they are effective, choice of the right antidepressant for a particular patient is of great importance. Unfortunately, there is very little evidence upon which to base such a decision. Reliable predictors of response to a particular antidepressant drug or class of drugs, do not exist. We have developed a treatment algorithm for non-psychotic, unipolar, major depression that is applied in our clinic. It involves progression from a specific serotonin reuptake inhibitor (SSRI), usually fluoxetine at a dose of 20 mg, to a 40 mg dose in patients whose response is inadequate after 4 weeks. Response is evaluated by the Clinical Global Impressions Scale (CGI). Non-responders to SSRI receive augmentation with triiodothyronine (T3) at doses of 25mcg-50mcg for up to three weeks. Patients that do not respond, then go on to receive a tricyclic antidepressant (clomipramine according to plasma levels) or a serotonin and norepinephrine reuptake inhibitor (SNRI, venlafaxine, at doses of 150mg-225mg). The algorithm has further steps but these are not presently relevant. Hamilton Depression and Visual Analogue Scales are also recorded. Thus far, 72 patients have been treated according to this algorithm. An interim analysis has been performed on the first 66 (42 females). 59% responded (CGI-B, 2 or less) to SSRI at a dose of 20mg. The factors most consistently associated with response were less severe depression (p=.001), first episode of major depression (p=.003), absence of melancholic features (p=.02), absence of family history of psychiatric illness (p=.03) and recent negative life events (p=.03). Raising the SSRI dose to 40 mg was strikingly ineffective (only 2 of 27 patients responded). 25 patients went on to receive triiodothyronine (T3) augmentation. T3 was effective in 7 of them. All the patients who responded to T3 augmentation were women (7/16, p=.02). The patients who responded to T3 augmentation tended to be less severely depressed than those who did not (p=.04). Of the non-responders up to this point in the algorithm, 13 out of 18 responded to TCA/SNRI. These findings suggest a role for T3 augmentation in depressed women who have not responded to SSRI treatment. Further analyses of a larger sample will be presented. Clinical experience with T3 augmentation in posttraumatic stress disorder (PTSD), reflecting 4 cases without comorbid major depression who responded to T3 augmentation of SSRI, will also be discussed.
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