The Carlat Psychiatry Podcast Hidden Gems: Pramipexole Part II
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Mar 2, 2026 A concise dive into using pramipexole for treatment-resistant depression. Discussion covers why effective options are often underused and how to personalize care. Practical tips on dosing, titration, and managing side effects are shared. Risks like impulse issues, cardiac concerns, and sleep attacks are reviewed.
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Inverted Evidence Pyramid In Treatment Resistant Depression
- Psychiatry often favors popular but less effective TRD treatments while stronger options sit unused at the bottom of evidence piles.
- Chris Aiken found an inverted pyramid: common treatments rank low in efficacy, while lithium, psychotherapy, and neuromodulation show stronger, longer-term benefits.
Prioritize Long Term And Personalized Treatments
- Prioritize long-term benefits: use neuromodulation, psychotherapy, lifestyle, and maintenance strategies over short-lived polypharmacy.
- Personalize for subtypes like bipolar, mixed, inflammatory, seasonal, postpartum, or trauma-related depression.
Raising SSRI Dose Is Usually Ineffective In TRD
- Recent trials (Dupree 5) showed raising SSRI dose is ineffective as augmentation in TRD.
- The trial used dose-raising as a placebo comparator and found no benefit from increasing fluoxetine from 20 to 40 mg.
