Mohammed T. Abou-Saleh

PHARMACOLOGICAL TREATMENT OF DEPRESSION 443depression. Flint and Rifat 4 found that seven of 15 elderly patients(47%) who had failed to respond to 6 weeks of nortriptylinefollowed by 2 weeks of lithium augmentation subsequentlyresponded to a 6 week trial of phenelzine. This rate of responseis comparable to that reported among younger patients refractoryto TCAs 5 . Data obtained from mixed-aged patients with resistantdepression suggest that switching to an antidepressant within thesame class is less effective than switching to one from anotherclass 5 . If a patient has failed to respond to an SSRI or nefazodone,then switching to an antidepressant with dual neurotransmitteraction (e.g. venlafaxine, mirtazapine or nortriptyline) is a reasonableapproach.Although substitution of treatment usually involves switchingfrom one antidepressant medication to another, switching from anantidepressant to ECT should also be considered. The efficacy ofECT in patients who have failed to respond to adequate antidepressantpharmacotherapy is lower than in patients withoutestablished medication resistance 6 . Nevertheless, no antidepressant,alone or in combination, has been shown to be more effectivethan ECT in treatment-resistant depression and ECT remains avaluable option in this situation.REFERENCES1. Schneider LS. Pharmacologic considerations in the treatment of latelifedepression. Am J Geriat Psychiat 1996; 4(suppl 1): S51–65.2. Mulsant BH, Pollock BG. Treatment-resistant depression in late life. JGeriat Psychiat Neurol 1998; 11: 186–93.3. Flint AJ. Augmentation strategies in geriatric depression. Int J GeriatPsychiat 1995; 10: 137–46.4. Flint AJ, Rifat SL. The effect of sequential antidepressant treatment ongeriatric depression. J Affect Disord 1996; 36: 95–105.5. Thase ME, Rush AJ, Kasper S, Nemeroff CB. Tricyclics and newerantidepressant medications: treatment options for treatment-resistantdepressions. Depression 1994/1995, 2: 152–68.6. Prudic J, Haskett RF, Mulsant B et al. Resistance to antidepressantmedications and short-term clinical response to ECT. Am J Psychiat1996; 153: 985–92.