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CLINICAL SYNTHESIS   |    
Optimization of Treatment Algorithms for Clinical Depression: Glutamate Antagonists and Transcranial Magnetic Stimulation as Case Examples
Tracy L. Greer, Ph.D.; Madhukar H. Trivedi, M.D.
FOCUS 2014;12:146-151. doi:10.1176/appi.focus.12.2.146
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Author Information and CME Disclosure

Tracy L. Greer, Ph.D., Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX

Dr. Greer has received honoraria from and served as a consultant and on a task force for Lundbeck and received honoraria from and served on an advisory board for Takeda.

Madhukar H. Trivedi, M.D., Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX

In the last 12 months, Dr. Trivedi is or has been an advisor/consultant to Alkermes, AstraZeneca, Bristol-Myers Squibb, Cerecor, Concert Pharmaceuticals, Eli Lilly and Company, Forest Pharmaceuticals, Janssen /Johnson and Johnson, Lundbeck, MedAvante, Merck, Mitsubishi Tanabe Pharma Development America, Naurex, Neuronetics, Otsuka Pharmaceuticals, Pamlab, Phoeniz Marketing Solutions, Ridge Diagnostics, Roche, Shire Development, Sunovion, Takeda, and Vivus. In addition, he has received research support from Corcept Therapeutics, the National Institute of Mental Health, and the National Institute on Drug Abuse.

Address correspondence to Madhukar H. Trivedi, M.D., Betty Jo Hay Distinguished Chair in Mental Health, Department of Psychiatry, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9119; e-mail: Madhukar.Trivedi@UTSouthwestern.edu

Abstract

Clinical Context  Current treatment approaches for depression are still largely based on trial and error, necessitating adequate guidance for sequential treatment selection and maintenance. Issues surrounding the adequate implementation and integration of evidence-based treatment approaches, particularly as they relate to novel approaches and combination strategies, remain an important concern.

Treatment Strategies and Evidence  Treatment guidelines and algorithms have been associated with improved outcomes. Utilization of measurement-based care (MBC) provides a simple and effective way to optimize personalized evidence-based medical care based on current treatment guidelines. Because current treatments lead to only modest outcomes, incorporating the use of novel treatments is desirable. However, ways in which promising treatments can effectively and appropriately be incorporated into treatment algorithms requires careful assessment of risks and benefits.

Questions and Controversy  Utilization of treatment guidelines and algorithms in practice has been fairly slow to occur, although MBC approaches have aided in better adoption of evidence-based clinical practice guidelines into standard care. A balance must be struck between adopting insufficiently studied novel treatments and rapid dissemination of evidence-based treatments via treatment guidelines and algorithms.

Recommendations  MBC is critical to personalization of evidence-based treatment selection and optimization of treatment outcomes. Incorporation of biomarker data into treatment selection and maintenance will be critical to improve personalization of treatment in the future.

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Table 1.Pivotal Clinical Trials of Ketaminea
Table Footer Note

a BDI , Beck Depression Inventory; HRSD, Hamilton Rating Scale for Depression; MADRS, Montgomery-Åsberg Depression Rating Scale; RCT, randomized clinical trial; TRD, treatment resistant depression.

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