Depression Symptoms Treatment

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Assessment of current treatment. The most frequent reason that a patient does not respond to treatment and becomes labeled as treatment resistant is the inappropriate use of antidepressants. Surveys reveal that two out of three cases of depression do not receive adequate treatment. Many patients are under the care of specialists. It has been well established, however, that 30% to 35% of patients do not respond to a course of antidepressants. Other factors commonly associated with treatment failure have been summarized by Akiskal and will be briefly discussed.

Pharmacologic factors: The dose and duration of an antidepressant drug trial must be adequate. In specialized mood clinics, researchers have found that under-treatment is the most common reason for treatment failure. For most tricyclics, an adequate drug trial requires at least 150 to 200 mg daily for 4 to 5 weeks. Monoamine oxidase inhibitors and the new hetero-cyclic agents also require a full 5 weeks. Unpleasant side effects can lead to non-compliance. Serum levels are sometimes subtherapeutic in spite of what seems to be an adequate dose.

Estimates of serum levels can play an important role in management and are usually readily available. Serum levels serve as a guideline only, because the precise range for most tricyclics has not been determined. The exception is nortriptyline, which has a “therapeutic window” and a therapeutic range of 70 to 140 ng/mL. For the other tricyclics, the range seems to be about 150 to 200 ng/mL. Serum levels are not readily available for the newer heterocyclics and the MAOIs.

Serum levels are useful for ensuring compliance; ensuring adequate absorption; assisting in dosage adjustment for special patient groups, such as the elderly or medically ill; and assisting in dose adjustment when severe or unusual side effects are present or when treatment apparendy fails.

Side effects, particularly those related to sexual functioning, are the most common cause of noncompliance. Most side effects are transient or, if persistent, can be easily managed. Patients should also be informed about the long latency of response.

Patient factors: Patients are reluctant to take antidepressants for many reasons: fear of reliance on a pharmacologic crutch, a sense of unworthiness to receive help, fear of addiction, worries about side effects, and delusional beliefs about being poisoned. Good patient education and a good therapeutic relationship are necessary.

Physician factors: Inadequate response to therapy can also be iatrogenic. A lack of understanding of the biologic basis of depression, failure to educate the patient and family, failure to conduct adequate treatment trials, and fear of prescribing MAOIs or ECT are some of the main factors (Table 4).