Steven Levine, MD: Let’s come back to TMS [transcranial magnetic stimulation] and ECT [electroconvulsive therapy], sticking first with first-line therapies with all the classes of medications and adverse effect profiles Patricia discussed. There are many examples of antidepressants that fall under each of those classes. Can any of you speak to what factors you consider when choosing a first-line antidepressant? What causes you then to potentially switch therapies either within a class or across classes?

Angelos Halaris, MD, PhD, APA, ACNP, CINP: Yes, I’d be happy to start by saying what I’ve increasingly been doing. Since the era of pharmacogenomic testing, I’ve become a proponent. I’ve seen excellent results with treatment-resistant depression in particular. Where appropriate, I do it from the get-go before the trial and error and hit or miss approach. That guides me in choosing what medication would be congruent.

In the absence, reluctance, or inability to cover the cost of this testing, depending on the symptom profile, do I need more of an activating or sedating antidepressant? That gives me flexibility to pick and choose between something more serotonergic vs more of an SNRI [serotonin-norepinephrine reuptake inhibitor], like desvenlafaxine, which I like because it’s tolerated extremely well and does not lead to excessive sedation. If anything, it gives patients some energy and uplifts their mood. There’s even an antianxiety component, although it’s not very prominent. That’s the approach I take. I like MAOIs [monoamine oxidase inhibitors], especially the patch, selegiline, which is a great drug. I like it a lot. But for whatever reason, it’s not first line, for better or for worse.

Steven Levine, MD: Sadly, as we talked about earlier, no matter what approach you take, there’s a high probability that patients will not adequately respond to treatment at some point, hence the high rates of treatment resistance. Lisa, in those cases, would you like to address when you think about potentially referring patients for ECT or TMS?

Lisa Harding, MD: Yes. This hits home for me. Just before I graduated, I used to teach ECT to the medical students at Yale [University School of Medicine]. The first thing you have to talk about is getting over the stigma of One Flew Over the Cuckoo’s Nest. Once you get that out there and you get Jack Nicholson out of the way, this is a great treatment. Where does it fit into the algorithm? That’s the question. If we’re speaking about things like catatonia and psychosis, it’s a different conversation than where ECT fits into the algorithm of treatment-resistant depression. With anybody who has treatment resistance with psychosis, this is automatically my go-to.

One of my good friends and training buddies in residency was like, “I’ll just tattoo ‘ECT me’ on the inside of my arm if this ever happens to me,” because of that rapid alleviation of the symptoms. Also, for pregnant women who are acutely suicidal, this is the go-to I would use. I’m now a little more conservative with my younger patients with regard to the cognitive [adverse] effects. I’m thinking about TMS or a form of ketamine when I’m thinking about other forms of depression outside of psychosis and women who are acutely suicidal in pregnancy. Those are usually the ones I think of first.

Transcript Edited for Clarity