Titrating, Augmenting, and Switching, Oh My! Management of Depression Refractory to First-Line Therapies

Outcomes 1. Recognize common second- and third-line pharmacological and interventional strategies to manage depression in patients with serious illnesses and compare their effectiveness.2. Implement two alternative second-line approaches for managing depression in palliative care when initial antidepressant treatment proves ineffective. Key Message Depression impacts seriously ill patients; first-line treatments may not always work. This presentation introduces strategies for managing depression resistant to first-line treatment, providing palliative care providers with diverse pharmacological and interventional options beyond SSRIs. Expert insights on cross-tapering, medication augmentation, Ketamine, and ECT will enhance patient care. Introduction Depression is common among people with serious illnesses. Palliative care clinicians routinely manage depression as part of comprehensive serious illness care. Although pharmacological interventions comprise first-line therapy for patients with moderate or worse depression, around half of patients do not respond to initial medications. A range of strategies exist for patients with depression who do not benefit from initial antidepressant trial. However, some clinicians may feel unfamiliar or uneasy employing alternative pharmacological or interventional strategies when faced with such cases. Objectives We introduce cutting-edge approaches to addressing depression that does not respond to initial medication trial among palliative care patients. We aim to acquaint palliative care clinicians with high-yield pharmacological and interventional second-line approaches for depression. Methods/Results Our expert panel, comprising psychiatry-trained palliative care physicians and a palliative care pharmacist, will adopt a case-based approach to explore different strategies for managing resistant depression within the palliative care setting. Dr. Gregg Robbins-Welty will cover guidelines-based approaches for cross-tapering SSRIs and SNRIs, and switching between antidepressants. Dr. Paul Noufi will examine evidence-based pharmacological strategies for medication augmentation following SSRIs' failure in depression treatment. Dr. Joshua Borris will delve into the evidence supporting Ketamine's use for depression in patients with advanced medical illnesses. Dr. Daniel Shalev will present an overview of ECT, with a focus on its indications in palliative care patients. Conclusion Palliative care clinicians should be familiar with strategies for addressing treatment-resistance in depression among patients with serious illness. Equipping providers with diverse approaches can elevate patient care and improve quality of life. The expert panel's exploration of guidelines-based pharmacological and interventional methods offers promising avenues for effective depression management in this challenging setting. Keywords Emergencies / Refractory Symptom Management / Pharmacotherapeutics / Pharmacopalliation