Major depression is best managed through a treatment algorithm. The more resistant to treatment a patient’s illness is, the further treatment proceeds through the steps. As each trial of therapy is deemed ineffective, diagnosis should be reviewed and physical and psychosocial factors reassessed before making a decision about the next step. Psychotherapy is an essential accompaniment to any form of somatic treatment. Supportive psychotherapy offers reassurance and time for patients to talk about their pain and also provides support and education. Destructive lifestyles, guilt, low self-esteem, and anger are some of the issues that might need to be addressed. Some patients need to be referred for formal psychotherapy.

Strategies before changing antidepressants

Higher dose

For the new antidepressant compounds, most manufacturers recommend standard doses. If side effects are minimal, doses usually can be increased and tolerated well. Increasing the dose should be tried before adding other antidepressants or switching drugs.

Lithium augmentation

For patients who have failed to respond to an adequate course of an antidepressant, lithium augmentation is the most reasonable next step (Table 4 summarizes augmentation strategies). About 30% to 50% of patients respond to this technique, and it seems to work with all of the antidepressants (although less is known about how it works with the newer agents). Lithium, an antidepressant and mood stabilizer when used alone, appears to augment other drugs by enhancing postsynaptic receptor sensitivity.

To use this technique, the antidepressant should be continued at the current dose and lithium started at a dose of 300 mg three times a day. A positive response can occur in 5 to 12 days. If the response is positive, patients should continue to receive lithium for at least 6 months and in some cases for the duration of antidepressant therapy. Lithium levels should be monitored and kept within the therapeutic range of 0.6 to 1.0 mmol/L, and thyroid status should be closely followed.

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