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

---

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

How to Put an End to Depression

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

Get Rid Of Depression Once And For All

Depression is something that will occur in many people's lives,... Read More

More Than You Can Handle?

There's a dangerous illness afflicting women everywhere across the nation.... Read More

Anxiety and Depression - Why Depression Drugs May Not Be Necessary - Fight Depression Naturally

Millions of people, especially in the United States, are currently... Read More

Use Alternative Medicine to Ease Depression

Depression is a problem that faces many of us, young... Read More

Hurricane Recovery: Steps to Start Putting Your Life Back in Order

It seems unreal, another major storm hitting Florida after experiencing... Read More

Depression - Causes and Treatments

Depression has long been considered a character flaw indicative of... Read More

Recognizing Depression?s Warning Signs

Depression is a serious illness, not a harmless part of... Read More

Efficacy and Safety of Vagus Nerve Stimulation for Depression Published in Journal

On September 1st, the efficacy and safety of vagus nerve... Read More

FDA Approves Vagus Nerve Stimulation as a Treatment for Depression

On July 15th, 2005, the U.S. Food and Drug Administration(FDA)... 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

Depression: Based on a True Story

"Ring, ring." The crisis operator answers the phone to a... 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

What?s Causing My Depression and Fatigue?

Chronic Fatigue and Chronic Depression are absolutely systemic in our... Read More

Your Daily Struggle With Depression

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

Chronic Depression: Disease or Charcter Flaw?

A major survey on depression symptoms from the National Mental... Read More

First Thing You Should Do to Get Out of Depression

Depression, in psychiatry, is a symptom of mood disorder characterized... Read More

The Formula for Preventing Depression

While it is arguable that depression is not always preventable,... Read More

5 Ways to Transform Your Struggles Into Victories

Have you read the famous quote, "Every struggle is a... Read More

Psychiatrist Begin Training About Vagus Nerve Stimulation for Depression

The manufacturer of the vagus nerve stimulator has begun face-to... Read More

Omega 3 EPA: Natures Very Own Anti-depressant

Since Dr Malcolm Peet, a consultant psychiatrist at Sheffield swallow... Read More

Recognizing Depression

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

Natural Remedies For Depression

It is true that forms of depression cannot be avoided,... Read More

Quick Steps To Improve Your Mood

Looking to improve your mood?Edward W. Smith, motivational speaker, author... 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

Is it ADHD or is it Depression?

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

Depression: 14 Universal Laws for Recovery

The Law of BlueJust sort of feeling blue, kinda out... Read More

Are the Benefits Worth the Costs?

Schizophrenia suffers around the world have benefitted greatly with the... Read More

American Indian Youth and Depression - Using Traditions To Heal The Wounds

When most people hear the words American Indian, visions of... Read More

5 Surefire Tips to Beat Depression Now

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

Depression And Celiac Disease

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