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


Wellbutrin For Depression: When Its More Than Just The Blues

We all have blue days:We're missing someone we've lost, the... Read More

Everyday I have the Blues: A Medical Intuitive look at Depression

It may come in waves, it may control our lives.... Read More

Depression in Teenagers: Now What Can We Do?

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

How to Put an End to Depression

Depression can have many, many faces. If you are not... Read More

Depression Explained

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

Your Daily Struggle With Depression

If you have been diagnosed with depression or feel that... Read More

Disability is NOT a Life Sentence

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

5 Tips to Reduce Depression

While war and poor economic conditions begin to affect people... Read More

Recognizing Depression

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

Is it ADHD or is it Depression?

During the assessment process it is of great importance for... Read More

5 Surefire Tips to Beat Depression Now

Being lonely is a normal part of our everyday lives...... Read More

Depression and EPA Fish Oil - Does It Really Work?

It is now no secret that people all over the... Read More

Manic Depressive Episodes And Scientology

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

What Is God Thinking?

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

New Treatment for Depression to be Presented at the American Psychiatric Association Annual Meeting

Within the next few weeks, the FDA is expected to... Read More

A Look at the Different Depression and Anxiety Medications

While it may be easy to recite the various brand... Read More

How Do You Know if You Have Manic-Depression

Nancy was doing very well until about two years ago... Read More

Antidepressants 101- What You Absolutely Need to Know

IntroductionChange in social and economical states throughout the world although... Read More

Can You Overcome Depression?

There are many things that happen within the body when... Read More

New Treatment for Depression to be FDA Approved by Late June

With the next few weeks, the FDA is expected to... Read More

Biological Psychiatry Confirms of Efficacy and Safety of VNS Therapy for Depression

The September 1, 2005 issue of Biological Psychiatry confirmed the... Read More

Tips to Beat Depression

We all have days when we are down, worn out... 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

Major Symposium About Vagus Nerve Stimulation & Depression at the American Psychiatric Association

A major symposium about vagus nerve stimulation as a treatment... Read More

Raise Your Feeling Frequency with a Loving Smile

In every moment of our life we have the choice... Read More

ADHD and Depression -- More Common Than Thought

"Thanks for Noticin' Me" says Eeyore. He walks slowly. He... Read More

Mood Disorders And Depression

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

Fighting Depression by Restoring Your Routines

When we have depression, one of the things we drop... Read More

Change Your Life Forever with New Medical Breakthrough Treatment for Depression

With the next few weeks, the FDA is expected to... Read More

5 Super Effective Tips To Kill Depression

Being lonely is a normal part of our everyday lives.... 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

Chronic Fatigue Syndrome And Depression Are Not The Same Thing!

Chronic Fatigue Syndrome is a... Read More

Seven Ways To Deal With Your Depression

It has just been announced, after a study by a... Read More