Primapexol has moved up in our algorithm for treatment-resistant depression.

Today, learn how to use this dopamine agonist.

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

I'm Chris Sagan, the editor-in-chief of the Carlat Psychiatry Report. And I'm Kelly Newsom, a

psychiatric MP, and a dedicated reader of every issue. I've spent the past year gathering

every controlled trial I can find on treatment-resistant depression, and when I stepped back

to look at the pile, I saw a concerning

pattern. It was an inverted pyramid. The treatments that are popular at the top are the least

likely to work, while the ones that have the strongest effects fall to the bottom and are very

rarely used. When antidepressants don't work, people switch classes, raise the dose, or add in other

antidepressants or stimulants, benzos, lomotrogen, or buspirone.

If they are following practice guidelines, they'll probably augment with an antipsychotic,

but those medications only work for a few months in what is usually a chronic disorder.

The industry has tried to get approval for antipsychotics as long-term maintenance agents

and depression, but they failed in three out of four large industry-sponsored trials that tested

them for just six months, which the industry defines as long-term. By contrast, lithium worked

long-term in a meta-analysis of 21 controlled trials that lasted an average of two years

in unipolar, not bipolar, but unipolar depression.

And psychotherapy has better long-term results than antidepressants in depression.

But how often do you see a patient with treatment-resistant depression who has tried TMS?

In recent trials, TMS was more effective than pharmacological augmentation.

And how often have they tried accelerated or saint TMS, an accelerated five-day protocol

...