Depression

Depression: My Antidepressant Doesn’t Work. What Can My Psychiatrist Do?

Depression: My Antidepressant Doesn’t Work. What Can My Psychiatrist Do?

 

Depression | 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 dhopeless. 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.

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.

 

FAQ

What actually causes depression?

Research suggests that depression doesn’t spring from simply having too much or too little of certain brain chemicals. Rather, there are many possible causes of depression, including faulty mood regulation by the brain, genetic vulnerability, stressful life events, medications, and medical problems.

What do you do when antidepressants don’t work for you?

If your depression symptoms return for more than a few days, it’s time to see your doctor. But even if you feel like your antidepressant isn’t working, it’s important to keep taking it until your doctor advises otherwise. You may need a dosage increase or a slow tapering off process.

What is it called when antidepressants stop working?

But because they treat the symptoms of depression, and not the underlying cause, the effectiveness of these medications may not be lasting. For many people with depression, medicines that have helped may, at some point, seem to stop working. This loss of effectiveness is called tachyphylaxis.

Which of the following is seen as an effective treatment for severe depression that does not respond to drug therapy?

Electroconvulsive therapy (ECT) is a medical treatment most commonly used in patients with severe major depression or bipolar disorder that has not responded to other treatments.

How do you know when antidepressants stop working?

Signs that your antidepressant might not be working include: You feel more or the same amount of sadness, anxiety, or irritability after several weeks or months of taking the medication. You feel slightly better, but still feel that your depression is affecting your ability to function. You are having trouble sleeping.

Can you still have bad days on antidepressants?

What if I continue having good and bad days? You may be having a partial response to the drug. If you have residual symptoms, your depression is more likely to return. Many people feel so much better with medication that they dismiss such symptoms as just having a “little” trouble sleeping or a “slight” energy problem.

Is three  hope for treatment-resistant depression?

For treatment-resistant depression, there is always hope. As difficult as it may seem to deal with the symptoms of treatment-resistant depression, there are many different ways to approach it and, with patience and support, you will achieve relief.

What is the strongest antidepressant medication?

The most effective antidepressant compared to placebo was the tricyclic antidepressant amitriptyline, which increased the chances of treatment response more than two-fold (odds ratio [OR] 2.13, 95% credible interval [CrI] 1.89 to 2.41).

Can antidepressants make you lose motivation?

Selective serotonin reuptake inhibitors (SSRIs), commonly used to treat depression, are associated with loss of motivation, anergy, and lack of curiosity often referred collectively as apathy.

Do you feel worse after starting antidepressants?

When you start an antidepressant medicine, you may feel worse before you feel better. This is because the side effects often happen before your symptoms improve. Remember: Over time, many of the side effects of the medicine go down and the benefits increase.

Can I take my antidepressant an hour late?

Generally you can take a skipped day, but before doing so consult with your doctor or pharmacist.” If it has been less than two hours since your scheduled dose, it is okay to go ahead and take your missed dose.