Maria has been more and more depressed for the previous couple of many years. She has tried at least 4 more recent antidepressants but so far, she doesn’t seem to react. Unable to function, she’s now feeling helpless and hopeless. Likewise, her family members is discouraged. Frustrated and baffled by Maria’s lack of progress, the family members doctor refers her to a psychiatrist.

What can the psychiatrist do to assist Maria?

The psychiatrist has several options in dealing with a treatment-resistant or refractory depression. Initial, Maria’s psychiatrist can optimize the dose of her antidepressant. Maria has been taking reduced 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 3 weeks. The antidepressant can be adjusted up to the optimum allowable dose if no or only partial response is observed.

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

Lately, research have proven atypical neuroleptics such as olanzapine and risperidone to be great augmenters. In my opinion, additional research are necessary to set up these two drugs as standard augmenter. Indeed, research research and clinical encounter have discovered augmentation strategy to be efficient.

3rd, mixture strategy is worthwhile to attempt. Maria’s psychiatrist can add an additional antidepressant to boost the effect of her present 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 entail several brain chemical substances has resulted in clinical improvement. In this situation, 1 antidepressant as well as an additional antidepressant is equal to 3, or 4 or even 10, not two.

Fourth, the psychiatrist can switch from 1 antidepressant to an additional. Previous research have proven that when making a switch, a drug should be changed 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 current research display that switching drugs inside the exact same class (e.g. SSRI to an additional SSRI) is just as efficient.

Fifth, Maria’s psychiatrist can also deal with other ongoing signs and symptoms or drug-associated problems that additional 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 including an antipsychotic drug should assist. Furthermore, medication side effects (such as insomnia, dryness of mouth, constipation, and so on.) that negatively impact Maria’s compliance to the drug should be addressed promptly.

Lastly, if despite above measures Maria doesn’t react to antidepressants, then electroconvulsive treatment should be entertained. Of program, this procedure should be carried out with her consent.

In summary, Maria’s psychiatrist can optimize the dose, augment or mix treatment, switch the medication, deal with side effects and ongoing signs and symptoms, or use electroconvulsive treatment for treatment-resistant or refractory depression.

About The Writer

Copyright © 2003. All rights reserved. Dr. Michael G. Rayel ? author (Initial Help to Mental Sickness?Finalist, Reader’s Choice Award 2002), speaker, workshop leader, and psychiatrist. Dr. Rayel pioneers the Treatment Approach as a first help for mental wellness. To obtain free publication, go to www.drrayel.com. His books are obtainable at major online bookstores.

mike@drrayel.com