Juvenile-HD

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SECTION 1 - AT RISK
Age & Probability Chart
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SECTION 2 - GENETIC TESTING
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SECTION 3 - JHD
Coping With The Early Years
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HD - What Kids Are Saying
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SECTION 4 - SYMPTOM RECOGNITION
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Anxiety/Apathy/Irritability~HD
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Dehydration
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Depression-Understanding It
Depression-How To Help
Depression - Treatment Resistant Patient
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-Read If Your Child Is On Antidepressant
Disgust - Impaired Recognition in HD
Dissociative disorders
Driving - Physician's Guide
Dyslexia
Dyslexia Resources
Dystonia
Dystonia/Rigidity & Spasticity Physician's Guide
Dystonia-Predominant Adult-Onset HD
Epileptic Seizures and Epilepsy
Epilepsy-Seizures~PG
-Seizures ~Special Populations
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Fevers, sweating & menstural cycles in HD
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Hand muscle reflexes in HD
Hypothalamus - A Personal Theory
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Irritability~Temper Outburst Physician's Guide
Learning Disability
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Mood Disorder Rate In HD
Myoclonus (Movements)
Nails-What To Look For
Night Terrors
Obsessive Compulsive OCD
Panic Disorder
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Prosody - Social Impairment
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Smoking-Physician's Guide
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Tremors
Why Certain Symptoms Occur
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SECTION 5 - COMMUNICATION
Communication Resources
Communication Problems
Communication Strategies For HD~Jeff Searle
SECTION 6 - EATING/SWALLOWING/NUITRITION
Hints For Weight Loss in HD
HD & Diet~HSA Fact Sheet 7
Nutrients: Some Possible Deficiency Symptoms
Nutrition and HD~Anna Gaba (Recipes)
Nutrition Information In HD~Naomi Lundeen
Speech & Swallowing~Lynn Rhodes
Swallowing & Nutrition Physician's Guide To HD
Swallowing & Nuitrition Resources
Swallowing Warning Signs
5 Swallowing Problems
Taste changes in HD
Weight Gain
Resources-Drinks/Shakes
-Feeding Tubes~Advanced Stages of HD
-Feeding Tube~Jean Miller
-Feeding Tubes: One More Word ~Jean Miller
-Feeding Tubes & Baby Foods
-Feeding Tube~Dental Care
-Feeding Tube Instructions~Jean Miller
-Feeding Tube Resources
SECTION 7 - THERAPIES
Finding a Therapist - Behavoir
What Is A Physiotherapist?
Physical Therapy In HD
Speech-Language Therapy
Therapy Descriptions
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Therapy Resources
SECTION 8 - MEDICATIONS
HD Treatments
Medications-Movement Disorders
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Cutting Prescriptions
Drugs-Look 'Em Up
-Adolescents Under 25
-Antidepressant Adverse Effects
-Anti-psychotic
-Anxiety-Antidepressant
A-Z Mental Health Drugs
-Creatine
-EPA~Fish Oil
-Haldol/Haloperidol - Clinical Sheet
-Haldol~Clinician Description
-Haldol & HD
-Haldol/HD Patient Experiences
-Haldol~ Patient Handout
-Mood Stabilizers: ASK 3 Questions
-Neuroleptic Malignant Synd WARNING
-Olanzipine-Risperidone/blood tests
-Celexa/Luvox/Paxil/Prozac/Zoloft
-Psychiatric Drugs & Children
Sertraline ~Zoloft
-Spasticity Meds/Treatments
-SSRI Medications
-Tardive Dyskinesia WARNING
-Weight Gain Medications
-Sites/Help the Medicine Go Down
-Vitamin & Mineral Deficiencies
SECTION 9 - SURGERIES
Surgery-Movement Disorders
o Surgery Resources
SECTION 10 - PROCEDURES
Clinic Visits-How To Prepare
CT Scans, MRI's etc.
Swallowing Tests
Tests Commonly Used
o Procedures Resources
SECTION 11- ALCOHOL/DRUGS
Alcohol-Parent's Guide
Alcohol-Talking To Your Child
Drugs-What To Do?
Drugs-Talking To Your Child
Disciplining-Ages 0-13 & Up
SECTION 12- SUICIDE
Straight Talk On Suicide
Teen Suicide-You Need To Know
o Suicide Resources
SECTION 13 - DIVORCE
Divorce & Child Stress
Tips For Divorcing Parents
SECTION 14 - DISABILITY ISSUES
Guides To Disability Issues
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Caring for a Seriously Ill Child
Child Long Term Illness
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IFSP Early Intervention Process
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Wishes Can Come True-Children's Wish Foundations
Special Needs Resources
Special Needs Camp - About
Special Needs Camp - Finding One
SECTION 15 - ASSISTIVE TECHNOLOGY
Child Assistive Technology
Adaptive Equipment Resources
Products
SECTION 16 - EMOTIONAL ISSUES
Signs of Unhealthy Self-Esteem
Emotional Behavior Links
o Emotional Support Resources
SECTION 17 - GRIEF
Helping Child Deal With Death
o Grief Addtional Resources
SECTION 18 - ADD/ADHD
ADD & Teens
Conduct Disorders
FAQS & Related Info
Understanding AD/HD
What Is AD/HD?
Research Articles
Resources
SECTION 19 - HD SUPPORT GROUPS
HD Support Groups
National Youth Association
SECTION 20 - HD LINKS
HD Links
Related Resources
Tips For Friends
SECTION 21 - BENEFITS/INSURNACE
HD Disability
Benefits Check UP - See What You Can Get
Medical Insurance Bureau's Facts On You!
Medicare-Medicaid
Medicare Rights-Home Health & Hospice
Medicare Rights Center Resources
No Insurance? Try This!
Prescription Drug Cards Part I
Prescription Drug Cards Part II
Social Security-Children With Disabilities
SECTION 22 - ARTICLES/JHD
JHD and ADD
SECTION 23 - CAREGIVING
Articles-Resources
Caregiver Self-Assessment
Caregiver's Handbook
"First Shift With A Person With HD"
Getting Respite Care/Help At Home
Helpful Forms-Info
Home Emergency Preparations
Symptom Management
Ten Tips
Useful Tools
SECTION 24 - BIO
Our Personal Experience
Coping At The End
Kelly E. Miller
Song & Verse
Letter From My Heart
GUESTBOOK
Depression - Treatment Resistant Patient

INDEX Page

Explains maximum dosages of which medications and what to switch to or combine with if they aren't working

--------------------------------------------------------------
Depression and the Treatment-Resistant Patient

Treatment resistance to antidepressant medication is a common problem that psychiatrists face with depressed patients.
 
An Agency for Health Care Policy and Research (AHCPR) Guideline review found that only 50% of patients respond positively to an initial antidepressant prescription. Moreover, only about one third of depressed
patients meet remission criteria after initial pharmacologic treatment.

Richard Shelton, MD,of Vanderbilt University, Nashville, Tennessee, reviewed the "4 Ds " to keep in mind when treating patients with treatment-resistant depression --
  • Diagnosis
  • Drug
  • Duration and
  • Different Treatments


Making the correct diagnosis is, of course, essential. Physicians should carefully review the diagnosis when treatment resistance occurs to ensure the patient does not have significant drug or alcohol problems, bipolar disorder, psychotic depression, or schizoaffective disorder. These disorders require other first-line treatments and can be associated with lack of response to antidepressant agents.

It is also essential to titrate antidepressant dosages to maximum before declaring a patient treatment resistant. These maximum dosages for selective serotonin reuptake inhibitors (SSRIs) are:

  • fluoxetine 40 mg, paroxetine 50-60 mg
  • citalopram 50-60 mg
  • sertraline 200 mg

A switch to an atypical agent, such as venlafaxine, mirtazapine, bupropion, or serzone is optimal for patients who are unresponsive to maximum dosages of SSRIs.

Tricyclic antidepressants, such as nortriptyline, may also be effective in patients not responding to SSRIs.

Another research tested modality for treatment-resistant depression is to augment an initial agent, such as an SSRI, with a second medication. The best tested agents shown to be effective in augmenting an initial antidepressant agent are lithium and liothyronine sodium. Lithium augmentation has been shown to be associated with a 50%
response rate across multiple trials.

Open trials have also suggested that bupropion augmentation of SSRIs and tricyclic augmentation of SSRIs may be effective.[11]

The single most effective modality to approach treatment resistance with remains electroconvulsive therapy (ECT) which has about a 70% response rate. One problem with ECT is that many patients relapse over the next year, and recent studies suggest that both maintenance treatment with an antidepressant and lithium and maintenance ECT after an initial course of ECT decreases relapse rates.

Several studies have suggested that the addition of cognitive-behavioral therapy to patients showing antidepressant treatment resistance may also enhance treatment response.

In a recent study of patients with chronic major depression, nefazodone and cognitive-behavioral treatment was more effective than either of these modalities alone.

The reports suggest that most people with treatment-resistant depression can be successfully managed, but more studies are needed help optimize our treatment choices. Several ongoing studies, such as the Sequenced
Treatment Alternatives to Relieve Depression (STAR-D) study funded by National Institute of Mental Health (NIMH) should provide important new information in the near future.

Source: Medscape
154th Annual Meeting of the American Psychiatric Association
Day 1 - May 5, 2001
The Impact of Major Depression in Patients With Chronic Medical Illness
Wayne Katon, MD

___________________________________________________________

May 12, 2001

Might be a consideration when medication isn't working for depression.  As noted, it is expensive

- US Food and Drug Administration has agreed to an expedited review of the study. With FDA approval, the coding is already in place for reimbursement  by Medicare and Medicaid.
 

This article suggests people putting pressure on the FDA to approved for insurance coverage.
-Approved in Canada and Europe early 2001
--------------------------------------------------------------------------------
MedscapeWire
Vagus Nerve Stimulation Shows Promise in Treating Resistant Depression
May 9, 2001 By Carla Cantor

New Orleans - Evidence is mounting that vagus nerve stimulation (VNS), used to treat severe epileptic seizures, is effective in treating depression that has not responded to other therapies.

In the first nationwide clinical trial of its kind, presented at the annual meeting of the American Psychiatric Association in New Orleans, Louisiana, investigators from the Baylor College of Medicine in Houston, Texas, reported that nearly half of patients with treatment-resistant depression who had the VNS system implanted - dubbed by some as a pacemaker for the brain - were doing well a year later.

Of 60 patients enrolled in the study at 4 medical centers, 30% showed at least a 50% or better improvement in depression and quality of life after 10 weeks of VNS treatment. Data presented on the first 30 patients showed sustained or further improvements after a year: 46% had significantly improved or were free of depression. The patients had suffered from depression an average of 10 years; most had failed numerous treatments, from electric shock therapy to combinations of antidepressants.

"At the evaluation one year after the implant the majority of patients who had responded acutely to VNS seemed to be holding their own - even doing better," says Lauren B. Marangell, MD, lead author of the study and director of mood disorders research at Baylor. The findings took researchers by surprise. "A continuing improvement in response rates for refractory depression is highly unusual," Dr. Marangell says, suggesting that VNS may become more potent over time.

The study, which began in 1998, should offer hope to the nearly 20 million Americans 18 and older who struggle with depression in a given year. According to the National Institute of Mental Health, 2-3 of 10 people with the disorder suffer from refractory depression.

Scientists don't know exactly how VNS acts in the brain to cause an antidepressant effect. They suspect that the electrical stimulation increases the activities of some neurotransmitters, such as serotonin, while decreasing the actions of others. A generator about the size of a pacemaker is implanted in the patient's upper chest and connected via electrodes to the left vagus nerve in the neck, which communicates messages to the brain.

The device is programmed to deliver electrical current every 5 minutes, and researchers say the adverse effects of VNS are minimal. As the nerve is stimulated, some people may experience a tingling sensation, hoarseness, or the urge to cough.

In April, the VNS system, manufactured by Cyberonics, Inc., of Houston, was approved in Canada (and a few weeks before that in Europe) for treatment of resistant depression - both unipolar and bipolar. It has been approved in the United States since 1997 for epilepsy and has been used by more than 12,000 people worldwide.

Meanwhile, investigators are in the midst of the first controlled study of VNS implanted in 210 patients at 21 sites across the US and Canada. The trial began a year ago and data should be available by mid-2002. Each study participant received the device, but in half of the patients, it was turned off for 3 months to compare their responses to the VNS group. (All of the patients had been informed of the possibility that the generator could be turned off for part of the study).

Citing the importance of finding a breakthrough treatment for refractory depression, the US Food and Drug Administration has agreed to an expedited review of the study. Marangell says that this is particularly exciting because with FDA approval, the coding is already in place for reimbursement by Medicare and Medicaid.

"What a lot of patients like about VNS is that it legitimizes depression as a medical condition in a  way that Prozac doesn't," she says. But VNS is expensive, and insurance coverage - even for treatment of epilepsy -varies widely. The device itself costs $12,000 and a neurosurgeon who implants it may charge another $10,000 to $15,000. The battery lasts 10 to 12 years.

James A. Halikas, MD, a professor of psychiatry at the University of Minnesota attending the APA  meeting, suggests that people who feel they may be candidates for the device put pressure on the FDA to increase the probability of timely approval. "In my practice, I see a lot of patients for whom therapy hasn't worked. Many would line up for an implant if VNS was covered by insurance."

Souce: Medscape