If antidepressant is not working, what to do next?
It can be
disheartening when you do not feel better after a medication has been
started. The pharmaceutical companies advertise their antidepressant
medications in ways that suggest almost "miraculous" recovery. The
reality is that the response rate to any give antidepressant tends to be
approximately 60% to 70% in clinical trials. This means a good portion of
individuals (more than 30%) would not be expected to see improvement on
the first medical tried. However, if a medication is not working, several
factors first need to be considered: How long has the medication been
taken? Is the dose high enough? Is the medication being taken as
prescribed?
It takes from
4 to 6 weeks (sometimes up to 8 weeks) for the full effect of an
antidepressant to take place (after an adequate dose has been
prescribed). Oftentimes, the dose of medication has not been optimized.
As long as there are few or tolerable side effects, the dose can be
pushed to the maximum recommended dosage. Your doctor may want to go past
the typical maximum dose if you have no side effects and have partially
responded to the treatment. However, in general, once the maximum dose
has been prescribed for up to 6 weeks, and you have been taking it as
prescribed, an adequate medication trial has occurred.
If there is no
improvement, a switch to another medication should be made. The change
can even be within a class; for example, a lack of response to one SSRI
does not mean the same will be true for another SSRI. If there is a
partial response, your doctor may want to augment with another
medication. Augmentation strategies generally involve using a medication
with a different mechanism of action so that different neurotransmitter
systems can come into play to help, similar to what cardiologists do when
they prescribe antihypertensive medication to patients whole blood
pressure remains elevated after an initial antihypertensive has been
prescribed. Thus, if treatment with a given agent fails, management
techniques include switches within a class, switches to another class,
augmentation, the use of medications other than antidepressants, and ECT
for more refractory depression.
It is very
important to be open with your doctor about your level of compliance with
a given medication. It is not unusual for people to forget doses or skip
doses for specific reasons. People often do not want to admit this to
their doctor, as they think he or she will become upset with them. If you
are having problems with taking your medication, it is extremely
important for your doctor to know so that the two of you can discuss some
of the barriers to taking it, such as side effects. A lack of efficacy is
often due to regularly missed doses, and without this knowledge, other
medications trials may be suggested unnecessarily.
