This study showed a benefit of T3 used to augment partial or incomplete response to TCA monotherapy.34 Stimulants such as amphetamine, methylphenidate, and pemoline, if used judiciously, and taken responsibly, can be effective in achieving a quicker response in patients with resistant, depression. These should be avoided in patients with a history of substance abuse and patients should be informed about the potential, though minimal, risk of developing tolerence.35-37 There has also more recent interest, in exploring modafanil for TRD.38 Evidence indicates that dopamine may have a role in the pathogenesis of depression.39 Dopaminergic agents such as bromocriptine, Inhibitors,research,lifescience,medical pergolidc,

and pramipexole are reported to be useful adjuncts for patients with TRD.40 The serotonin-dopamine receptor antagonism

of atypical antipsychotics has been suggested as a possible mechanism for the Selleckchem Doxorubicin antidepressant action of atypical antipsychotics. Recent studies have found that atypical antipsychotics may produce an antidepressant effect in schizophrenia Inhibitors,research,lifescience,medical and may be used either as an adjunctive medication or as an alternative to mood stabilizers in patients with affective disorders.41 Treatment-resistant psychotic depression is shown to be successfully treated with clozapine.42 The addition of risperidone to an SSRI among nonpsychotic depressed patients Inhibitors,research,lifescience,medical led to a rapid response among patients who had not responded to either fluoxetine or paroxetine treatment.43 A combination of olanzapine and fluoxetine showed superior efficacy to either olanzapine or fluoxetine monotherapy in patients with treatment-resistant depressive disorder without psychotic features.44 The presence of psychotic features, Inhibitors,research,lifescience,medical delusional depression, and bipolar depression may be indications

for the use of atypical antipsychotics.7 Other augmentation Inhibitors,research,lifescience,medical strategies include buspirone, pindolol, venlafaxine, mirtazapine, tianeptine, benzodiazepines, and anticonvulsant augmentation of antidepressants.30 Combination strategies This involves the addition to an antidepressant of a compound with a well-established efficacy as a single agent in the treatment of depression.30 Combination strategies include TCAs and SSRIs,TCAs and MAOIs, bupropion and SSRIs, anticonvulsants and antidepressants, and benzodiazepines and antidepressants.5 Terminal deoxynucleotidyl transferase However, SSRIs, venlafaxine, or clomipramine should not be combined with MAOIs and the MAOI and TCA combination should be used with caution. Switching strategies Switching involves stopping the antidepressant to which the patient is not responding and switching to another antidepressant, usually from a different class.45 Switching to an alternative antidepressant from a different class for SSRI nonresponders may be helpful.5 The options for SSRI nonresponders include using bupropion, nefazodone, venlafaxine, tianeptine, and mirtazapine. MAOIs may be used in TCA- or SSRI-resistant patients.