What to do if an initial antidepressant fails?
OBJECTIVE
To provide family physicians with practical ways of managing depressed patients responding insufficiently to initial antidepressant treatment.


METHODS
A search of MEDLINE and relevant bibliographies showed most studies could be categorized as level III evidence. Few well controlled studies (eg, level I evidence) specify treatment of next choice in rigorously defined treatment-refractory depression (TRD).


RESULTS
Failure to achieve and sustain full symptom remission affects relatively few treated depressed patients. Most chronically depressed people are not absolutely resistant but are relatively resistant to treatment; they fail to achieve the goals of treatment because of improper diagnosis or insufficient treatment application. The literature on TRD has largely focused on medication strategies; fewer studies investigated psychosocial approaches. The best established augmentation strategies are lithium salts and triidothyronine (T3). Combination antidepressants have become clinical psychiatrists' preferred treatment, despite limited evidence. Electroconvulsive therapy (ECT) remains a feasible option for TRD, but response rates are poor among people with TRD. High relapse rates after ECT remain a serious and common clinical dilemma.


CONCLUSIONS
Family physicians should familiarize themselves with some new strategies to modify inadequate response to initial antidepressant treatment.
Department of Psychiatry, University of Toronto, Ont. rmcintyr@uhnres.utoronto.ca
Roger S
RS
McIntyre
Aleksandra
A
Müller
Deborah A
DA
Mancini
Eric S
ES
Silver
D000465:Algorithms; D000928:Antidepressive Agents / Q000627:therapeutic use*; D003866:Depressive Disorder / Q000175:diagnosis / Q000188:drug therapy* / Q000628:therapy; D003937:Diagnosis, Differential; D004359:Drug Therapy, Combination; D006801:Humans; D012008:Recurrence; D017211:Treatment Failure
D000928:Antidepressive Agents