I remember all too well years ago the advertisements in psychiatric journals stating that antidepressants will “restore the person within the patient,” and although these medications have indeed made a dramatic difference in the outcome of depressive illness, they are by no means the miracle drugs that some thought them to be. In fact, a paltry 30 percent of depressed clients achieve remission (defined as a 50 percent reduction in the severity of symptoms via rating scale determination) on their first antidepressant trial with competent care.
Throughout the many years I have been treating depressed clients, I have come to think of depression not as a diagnosis, but instead as a constellation of symptoms with many possible causes. So what is the clinician to do after a patient did not benefit from the first antidepressant trial? The following list should be considered, but it is by no means exhaustive.
- Wrong diagnosis. Many subtypes of depression require treatment strategies that extend beyond a simple course of traditional antidepressant therapy. These subtypes include: seasonal affective disorder, atypical (anergic) depression, depression due to medical illness, comorbid substance abuse and bipolar depression, to name just a few. Conventional antidepressants (SSRIs, SNRIs, Wellbutrin) are typically not efficacious in bipolar depression. In the presence of nonresponse, the clinician will be well advised to reevaluate the initial diagnosis.
- Check the dose. Has the medication possibly been dosed too low? Has the client actually taken the medication as prescribed and for a long enough period of time (at least four weeks)? More often than not, a failure to respond may be due to inadequate compliance.
- Monitor for substance abuse. I’ve worked with few depressed clients who honestly report their use of alcohol or other illicit drugs. This is the ten ton gorilla in the room that must be addressed. Ongoing substance abuse in depressed clients sabotages their response to antidepressant medication – period!
- Augmentation. Augmentation refers to the addition of medication from different chemical classes or to the combination of antidepressants. Drugs that can be added to antidepressants include: lithium, thyroid supplements, stimulants, and second-generation antipsychotics. An increasingly common antidepressant combination is Cymbalta + Wellbutrin.
- Mechanical strategies. When pharmacological augmentation strategies don’t work, consider electroconvulsive treatment (ECT), transcranial magnetic stimulation (TMS), or vagal nerve stimulation (VNS).
The challenges inherent to treating clinical depression render it a particularly appropriate condition for a collaborative model of care. Non-medical clinicians and prescribers must work closely together to ensure the best possible results. Medication treatment and psychotherapy work hand-in-hand for providing hope to our clients, and well intentioned clinicians understand that when collaboration is frequent, meaningful and goal-directed, treatment outcomes are enhanced.