How do you start a new patient on antidepressant treatment? We do this countless times in our practices, and reviewing the topic may feel a bit like returning to residency. However, it’s important to revisit our standard operating procedures from time to time to ensure we’re thinking carefully about our decisions during our busy days.

You’ve tried different SSRIs and then some, but your patient either can’t tolerate what you’ve prescribed or simply hasn’t experienced a lift in mood. Now what? Dr. Gitlin has some ideas.

Your patient has now failed four antidepressant medications, both alone and as cocktails. What else can you pull out of your bag of tricks? Dr. Becker suggests considering transcranial magnetic stimulation (TMS), which he maintains is underutilized. “Many of my colleagues right down the hall from me still don’t think of TMS for treatment or don’t know who to refer for it,” he says. “I think it should be more readily considered for a lot of patients out there.”

For a look at how TMS works, how effective it is, how it compares with electroconvulsive therapy (ECT), whether some brands of TMS machines are better than others, and what you have to do to make sure your patient’s health insurance plan picks up the tab, we spoke with Dr. Becker, who prescribes this treatment for some of his patients.

Selective serotonin reuptake inhibitors (SSRIs) are considered the first-line treatment for depression; however, our confidence in their safety took a hit when the FDA issued a warning in 2011 about doses of citalopram above 40 mg causing QTc prolongation.

The pharmacological treatment of obsessive-compulsive disorder (OCD) for adults is pretty well worked out. Selective serotonin reuptake inhibitors (SSRIs) are the gold-standard treatment. We have multiple randomized, placebo-controlled trials to back this up. However, we know less about medication treatment of OCD for children.

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It’s no secret that SSRIs and SNRIs cause sexual dysfunction (SD) in a large proportion of patients who take them. The exact size of that proportion, though, is difficult to pinpoint with any reliability. Most of the large clinical trials of antidepressants ascertain side effects through spontaneous reports, and research subjects are understandably embarrassed about coming out and complaining about sexual problems.

Some smaller studies have shown that risperidone is useful as an adjunctive treatment for PTSD. But, in a larger-scale study with nearly 300 veterans, the medication used as an adjunct did not outperform placebo. To further explore the utility of atypical antipsychotics, researchers randomly assigned 80 VA patients with PTSD to monotherapy with placebo or quetiapine.

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