We look at the hidden gems of psychopharmacology, starting with Primapexall.

Welcome to the Carlythe Psychiatry podcast, keeping psychiatry honest since 2003.

I'm Chris Aiken, the editor-in-chief of the Carlat Psychiatry Report.

And I'm Kelly Newsom, a psychiatric MP and a dedicated reader of every issue.

In 2003, I opened a psychotherapy practice in Western North Carolina.

I didn't set out to focus on treatment-resistant depression,

but the problem came to my door, in patient after patient,

as it does for many in our field. In most towns, people get their first-line psychiatric treatment,

the SSRI, from primary care, and only come to us if that doesn't work. And for a lot of people,

it doesn't work. Somewhere between 30 and 60% of patients do not reach full recovery after two or more antidepressant trials.

That 30 to 60% range comes from different interpretations of the Stardee trial. The fact that it is such a wide range

tells us something important. Defining meaningful recovery is not an exact science. These patients

with treatment-resistant depression are really a varied bunch. They include older adults with vascular

disease, patients with bipolar features, inflammation, insulin resistance, dysthymic temperament,

childhood trauma, and chronic stress. And I learned pretty quickly in the 2000s that the algorithms we had to treat them, raise the

antidepressant, switch the class, ad buproprion, buspirone, or a stimulant, were not meeting

their needs.

This wasn't like antibiotic resistance, where they just need IV vancomycin or some other magic bullet.

These depressions I was seeing were complex and needed an approach from many angles,

lifestyle, nutrition, sleep, medication, psychotherapy, and sometimes neuromodulation.

The Star Day trial has a step-by-step algorithm for treatment-resistant depression

that reflects how psychiatry was practiced in the 1990s.

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