Home » Mind & Soul » Depression » Getting Smarter All the Time

Getting Smarter All the Time

© John McManamy

"In lieu of new meds, the trend has been to use the drugs we have in smarter ways."

The end of Eli Lilly’s monopoly on Prozac marks the end of an old era, but does it signal the beginning of a new one? Yes and no. For one, there have been no new antidepressants on the market in years, and the ones the drug companies have in the pipeline basically operate on the same principles as all their predecessors, including the ancient MAOIs and tricyclics, of targeting one or more of three of the brain’s neurotransmitters, albeit in much cleaner fashion.

In 1999, the National Depressive and Manic Depressive Association released a survey that found less than one in three to be happy with their antidepressants. That may change when antidepressants with better side effects profiles come on stream, but the era of a totally new antidepressant with a different mechanism (such as working on the stress hormone CRF or on substance P) is still years away.

In lieu of new meds, the trend has been to use the drugs we have in smarter ways. Both for depression and bipolar, combination therapy is now the norm, where two plus two hopefully equals five. The late nineties saw the introduction of meds treatment algorithms for depression and bipolar. Algorithms essentially ask "what next?" when the first treatment doesn’t work, and advance to further options based on science and clinical experience.

In 1996, the Texas Medication Algorithm Project (TMAP) was started to explore ways to develop cost effective mental health care in the public sector. Phase I involved developing guidelines based on scientific evidence and expert consensus, with publication following in 1999.

The TMAP algorithm for the medications treatment of depression resembles a seven-tier flow chart with boxes and connecting lines. SSRIs and other drugs recommended as monotherapy at first instance. If monotherapy with those drugs doesn't work, further options of monotherapy with different drugs or using drugs in various combinations present themselves. Stage four, for example, suggests augmenting an antidepressant with the bipolar medication lithium. By stage five, the situation begins to get desperate with the recommendation of ECT.

Algorithms are not meant to replace the judgment of skilled clinicians, but they do represent a welcome new era of rationality to traditionally the least scientific of the medical disciplines, and may compensate somewhat for the HMO-imposed 15-minute meds checks that now pass as consultations. Additionally, the patient benefits from knowing where he or she

The copyright of the article Getting Smarter All the Time in Depression is owned by Kathy Brewis. Permission to republish Getting Smarter All the Time in print or online must be granted by the author in writing.