Depression Series (Part 2): My Antidepressant Doesn?t Work - What Can My Psychiatrist Do?

Maria has been increasingly depressed for the past few years. She has tried at least four newer antidepressants but so far, she doesn't seem to respond. Unable to work, she's now feeling helpless and hopeless. Likewise, her family is discouraged. Frustrated and baffled by Maria's lack of progress, the family doctor refers her to a psychiatrist.

What can the psychiatrist do to help Maria?

The psychiatrist has several options in dealing with a treatment-resistant or refractory depression. First, Maria's psychiatrist can optimize the dose of her antidepressant. Maria has been taking low doses of antidepressants. In spite of her lack of response, the medication dosage has not been increased. To obtain a clinical response, her psychiatrist should increase the dose every two to three weeks. The antidepressant can be adjusted up to the maximum allowable dose if no or only partial response is observed.

Second, her psychiatrist can choose to augment the effect of her antidepressant with another medication such as lithium, triiodothyronine (T3), or buspirone. Among augmenters, lithium and triiodothyronine have the best support from the literature. Despite lithium's efficacy, some doctors avoid this drug because it requires regular blood monitoring and has unfavorable side effect profile such as acne, tremors, and thyroid and renal dysfunction.

Recently, studies have shown atypical neuroleptics such as olanzapine and risperidone to be good augmenters. In my opinion, further studies are necessary to establish these two drugs as standard augmenter. Indeed, research studies and clinical experience have found augmentation strategy to be effective.

Third, combination strategy is worthwhile to try. Maria's psychiatrist can add another antidepressant to boost the effect of her current antidepressant. For instance, trazodone can be added to an SSRI (serotonin reuptake inhibitor e.g. citalopram). Literature suggests that combining two drugs with different mechanisms of action and drugs that involve several brain chemicals has resulted in clinical improvement. In this scenario, one antidepressant plus another antidepressant is equal to three, or four or even ten, not two.

Fourth, the psychiatrist can switch from one antidepressant to another. Previous studies have shown that when making a switch, a drug should be replaced by a drug from a different class e.g. from SSRI to SNRI (serotonin and norepinephrine reuptake inhibitor e.g. venlafaxine), or from TCA (tricyclic agent e.g. nortriptyline) to SSRI. But recent studies show that switching drugs within the same class (e.g. SSRI to another SSRI) is just as effective.

Fifth, Maria's psychiatrist can also treat other ongoing symptoms or drug-related problems that further complicate her depression. If she is anxious and agitated, then her psychiatrist should prescribe antianxiety drug (e.g. lorazepam) or if Maria is psychotic then adding an antipsychotic drug should help. Moreover, medication side effects (such as insomnia, dryness of mouth, constipation, etc.) that negatively affect Maria's compliance to the drug should be addressed promptly.

Lastly, if despite above measures Maria doesn't respond to antidepressants, then electroconvulsive therapy should be entertained. Of course, this procedure should be done with her consent.

In summary, Maria's psychiatrist can optimize the dose, augment or combine treatment, switch the medication, treat side effects and ongoing symptoms, or use electroconvulsive therapy for treatment-resistant or refractory depression.

About The Author

Copyright © 2003. All rights reserved. Dr. Michael G. Rayel ? author (First Aid to Mental Illness?Finalist, Reader's Preference Choice Award 2002), speaker, workshop leader, and psychiatrist. Dr. Rayel pioneers the CARE Approach as a first aid for mental health. To receive free newsletter, visit www.drrayel.com. His books are available at major online bookstores.

mike@drrayel.com

In The News:


pen paper and inkwell


cat break through


Mood Disorders And Depression

We all suffer with bad moods from time to time.... Read More

Vagus Nerve Stimulation as a Treatment for Depression to be Launched in May

Final FDA approval of vagus nerve stimulation as a therapy... Read More

FDA Deems Vagus Nerve Therapy Approvable as a Treatment for Depression

On February 3, 2005 the U.S. Food and Drug Administration... Read More

When Your Fears and Depression Have the Best of You

What do you do when your fears and depression are... Read More

Depression in Teenagers: Now What Can We Do?

No doubt you have seen the recent news headlines about... Read More

Do You Think You Have Depression?

Do you have days where nothing can make you happy?... Read More

So You?ve Been Diagnosed with Bipolar Disorder?

If you've been diagnosed with bipolar disorder (also known as... Read More

Stress and Depression are Killing Us!

A short generation ago, families could set their watch by... Read More

Depression: Bringing Yourself Down

Sometimes it's hard to see the forest from the trees.... Read More

Depression Explained

Depression is a mental state marked by melancholy, pessimism or... Read More

Disability is NOT a Life Sentence

On September 30th 1998 I was crossing the street in... Read More

How to Uncover the Reason You Cant Sleep Tonight

If you are like me ...you love your sleep!Sleep deprivation... Read More

FDA Nears Completion of Review of Vagus Nerve Stimulation For Chronic Depression

On June 2 at 8:00 pm ET, Reuters news service... Read More

Depression And Celiac Disease

Depression is a condition which affects about 15% of the... Read More

Depression: What It Is and What You Can Do About It

There are three basic ways to treat depression: psychotherapy, self-help,... Read More

Recognizing Depression

Depression is a serious issue. There are simply hundreds of... Read More

Reclaiming Your Life From Anxiety Symptoms

Only somebody who has lived with anxiety ? as either... Read More

Depression Series (Part 2): My Antidepressant Doesn?t Work - What Can My Psychiatrist Do?

Maria has been increasingly depressed for the past few years.... Read More

What Is God Thinking?

What can you say to a parent who loses a... Read More

A Simple Cure For Anxiety And Depression

Our innate desire is to be happy, and when we... Read More

Senate Finance Committee Delays FDA Approval of Vagus Nerve Stimulation Therapy for Depression

On June 15th, 2004, FDA's Medical Devices Panel recommended that... Read More

Depression in Long Term Care Heart Patients Often Goes Untreated

Cardiologists, other doctors and long term care staff might be... Read More

Chronic Fatigue Syndrome And Depression Are Not The Same Thing!

Chronic Fatigue Syndrome is a... Read More

To Long Term Care Professionals: How to Dramatically Improve your Residents Psychiatric Care

Long term care facilities and residents' doctors should consider combining... Read More

10 Simple Coping Strategies When a Family Member Has Clinical Depression

1.Remember that it is an illness:Clinical depression often requires medical... Read More

Are You Someones Puppet? Four Ways People Manipulate Others

With the current interest in mental health topics, a mental... Read More

Depression After A Heart Attack

There are several factors can lead to depression after heart... Read More

Major Depression and Its Serious Complications

When suffering from clinical depression, people have different ways of... Read More

Manic Depressive Episodes And Scientology

Scientologists believe that chemical imbalances do not exist. In their... Read More

Sources of Online Suicide Help for People Suffering from Severe Depression

There are Many Resources for Online Suicide HelpFirst of all,... Read More

Depression

Many of us feel depressed at one time or another,... Read More

Depression is a Choice

There is one very simple reason for all emotional depression.In... Read More

I Love You, I Hate You But Dont Go: Understanding Borderline Personality Disorder

It amazes me that 6-10 million Americans have been diagnosed... Read More