0
1
+

Maximizing the Initial Treatment

+
Patients Treated With an Antidepressant

  • Optimizing (i.e., raising) the dose is a reasonable first step if side-effect burden is tolerable, especially if the upper dosage limit has not yet been reached.

  • Some patients may require doses higher than those approved by the Food and Drug Administration.

  • In patients who have shown a partial response, particularly those who have features of personality disorders and prominent psychosocial stressors, extending the antidepressant medication trial (e.g., by 4–8 weeks, but not indefinitely) can be considered.

+
Patients Treated With Psychotherapy

  • As for patients treated with an antidepressant, an initial strategy is to increase the intensity of treatment (i.e., increase the frequency of psychotherapy sessions).

  • The appropriateness of the type of psychotherapy used and the quality of the therapeutic alliance should be reviewed.

+

Changing to Other Treatments

  • For patients treated with psychotherapy, switching to an antidepressant medication can be considered. (Another option is to combine treatments, as described in the section that follows.)

  • For patients who do not show at least a partial response to an initial antidepressant, a common strategy is to change to a different non-MAOI antidepressant in the same class (e.g., from one SSRI to another SSRI) or in a different class (e.g., from a SSRI to a TCA).

  • For patients who can adhere to dietary and medication restrictions, a nonselective MAOI after sufficient washout period (Table 4) is an option.

  • Transdermal selegiline could be considered.

  • Recent evidence supports the efficacy of quetiapine monotherapy, but potential side effects need to be taken into consideration.

+

Augmenting and Combining Treatments

  • Pharmacotherapy combined with psychotherapy may offer advantages over either modality alone, particularly for patients with chronic, severe, or complex illness. For patients with less severe symptoms, advantages may be modest.

  • For patients treated with an antidepressant, augmentation strategies with a modest evidence base include the following:

    • Adding another non-MAOI antidepressant, generally from a different class

    • Adding lithium

    • Adding thyroid hormone

    • Adding a second-generation antipsychotic

  • Strategies with less supporting evidence include the following:

    • Adding an anticonvulsant

    • Adding omega-3 fatty acids

    • Adding folate

    • Adding a psychostimulant medication (e.g., modafinil)

    • If anxiety or insomnia is prominent, adding an anxiolytic or sedative-hypnotic medication, including buspirone, a benzodiazepine, or a selective gamma-aminobutyric acid (GABA) agonist hypnotic (e.g., zolpidem, eszopiclone)

+

Treatment-Resistant Depression

  • ECT is the most effective form of therapy for patients with treatment-resistant symptoms.

  • Another option to consider, with less supporting evidence, is transcranial magnetic stimulation.

  • Vagus nerve stimulation (VNS) may be an option for patients who have not responded to at least four adequate trials of antidepressant treatment, including ECT.

References

NOTE:
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