Dr. Michael Thase Answers Your Questions on Depression Treatments

In this occasional feature, members of the Psych Congress Steering Committee and faculty answer questions asked by attendees at Psych Congress meetings.

Michael E. Thase, MD, spoke at the 2020 Psych Congress Elevate conference on adjunctive and combination therapies for difficult-to-treat depression. Here, he answers some of the questions asked by attendees. 

Dr. Thase is Professor of Psychiatry, Perelman School of Medicine, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.

Q: Do you think the current heightened concern about benzodiazepine prescriptions is justified?
 

A: Given the interaction between benzodiazepines (BZ) and opiates, as well as increasing evidence that BZ therapy conveys additional risk in older patients—such as a heightened risk of falls and fractures—I believe that greater concern is justified.

Q: Why do psychiatrists prefer Cytomel (triiodothyronine; T3) over thyroxine (T4)?

A: The brain preferentially uses T3. Some of us are not able to convert T4 to T3. Until the genetic test is widely available and doesn’t cost more than one month of generic T3, it makes sense to prescribe T3 instead of T4.

Q: Because bupropion has a different effect than SSRIs, do they make a useful combo?
 
A: Yes, bupropion and mirtazapine are the two “safe” newer generation antidepressants that actually have effects that complement those of selective serotonin reuptake inhibitors (SSRIs) or serotonin–norepinephrine reuptake inhibitors (SNRIs). Although the evidence supporting use of these combinations is less sound (i.e., shakier)  than we’d prefer, I do believe that the combination of adding bupropion to an SSRI or SNRI makes sense as a second step treatment for about 25-50% of depressed patients.