Two Additional Aspects
In their article the authors provide a comprehensive and clear description of an evidenced-based stepwise therapy for unipolar depression (1). However, there are two further aspects that should be considered. First, the meta-analysis on antipsychotic augmentation (2) assumes comparable levels of efficacy for aripiprazole, olanzapine, quetiapine, and risperidone. That means that if, for example, the approved quetiapine cannot be used because of metabolic contraindications, aripiprazole would be available as a metabolic more neutral agent for evidence-based—albeit off-label—use. The drug has been approved in the United States for the indication of major depression. In addition, the substance will become available as a generic drug in 2015. The second aspects concerns the use of electroconvulsive therapy (ECT). In the light of the high relapse rates after successful acute treatment, the option of maintenance ECT should be mentioned as well. Although still limited, the available evidence supports a combined use of pharmacotherapy and ECT (3, 4) for relapse prevention; consequently, this approach has also been recommended as a treatment option in various guidelines (5).
Dr. med. David Zilles, MD
University Medical Center
Dpt. of Psychiatry und Psychotherapy
Conflict of interest statement
Dr. Zilles has received conference fees and reimbursement of travel expenses from Pfizer and Lundbeck.
|1.||Bschor T, Bauer M, Adli M: Chronic and treatment resistant depression —diagnosis and stepwise therapy. Dtsch Arztebl Int 2014; 111: 766–76 VOLLTEXT|
|2.||Nelson JC, Papakostas GI: Atypical antipsychotic augmentation in major depressive disorder: a meta-analysis of placebo-controlled randomized trials. Am J Psychiatry 2009; 166: 980–91 CrossRef MEDLINE|
|3.||Gagné GG Jr, Furman MJ, Carpenter LL, Price LH: Efficacy of continuation ECT and antidepressant drugs compared to long-term antidepressants alone in depressed patients. Am J Psychiatry 2000; 157: 1960–5 CrossRef|
|4.||Nordenskjöld A, Knorring L von, Ljung T, et al.: Continuation electroconvulsive therapy with pharmacotherapy versus pharmacotherapy alone for prevention of relapse of depression: a randomized controlled trial. J ECT 2013; 29: 86–92 CrossRef MEDLINE|
|5.||Zilles D, Wolff-Menzler C, Wiltfang J: [Electroconvulsive therapy for the treatment of major depression.] Nervenarzt. 2015; 86: 549–56 CrossRef MEDLINE|