Maria has been increasingly depressed for
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 hopeless. Likewise, her family is discouraged. Frustrated and baffled by Maria’s lack of progress, family doctor refers her to a psychiatrist. What can 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 dose of her antidepressant. Maria has been taking low doses of antidepressants. In spite of her lack of response, medication dosage has not been increased. To obtain a clinical response, her psychiatrist should increase dose every two to three weeks. The antidepressant can be adjusted up to maximum allowable dose if no or only partial response is observed.
Second, her psychiatrist can choose to augment effect of her antidepressant with another medication such as lithium, triiodothyronine (T3), or buspirone. Among augmenters, lithium and triiodothyronine have best support from 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 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.
