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.