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Notes:
Strategies
for Antidepressant Nonresponse
- Many approaches
have been developed for treating refractory depression, though few
are derived from controlled studies. Phillips, 1994:22 (4)
- Instead, researchers
and clinicians have clinically tested such strategies as optimization,
drug substitution, electroconvulsive therapy, drug combination, and
augmentation.
Optimization
- Ensuring that
a failed response to treatment does not result from inadequate treatment
is critical. Thus, optimization should be the first strategy employed
in patients who do not respond to the antidepressant. Joffe, 1996:25(4)
- Choice of antidepressant,
dose, and trial duration are factors to consider in determining whether
treatment was optimal. Joffe, 1996:25(5)
- An increasing
number of subtypes of major depressive disorder that respond to particular
classes of antidepressants have been identified.
- Antidepressant
underdosage has been a common cause of treatment failure. Thase, 1995:1084(4);
Joffe, 1995:7(1)
- Although
generally accepted guidelines for optimal dosing of antidepressants
exist, checking plasma levels is important because of differences
in individual patient metabolism. Phillips, 1994:21(2) ; Joffe,
1995:7(1)
- A minimum trial
of 6 weeks is necessary to afford the patient the best chance of therapeutic
response. Joffe, 1996:25(5)
Drug
substitution
- Ineffective
or partially effective drugs may be replaced with a new drug; this
is the usual and preferred clinical option. Joffe, 1996:25(6)
- Switching from
one antidepressant to another in the same class has not produced impressive
response rates.
- Controlled
studies document response rates of 10% to 30% in patients switched
from one tricyclic antidepressant (TCA) to another. Thase, 1995:1085(3)
- The success
of substitution may be enhanced by using a different class of antidepressant.
- Uncontrolled
trials suggest that switching from a TCA to an alternative antidepressant
class results in a 50% to 60% response rate. Joffe, 1996:25(5)
Combination
therapy
- Combination
therapy involves the addition of a second antidepressant agent
Augmentation
therapy
- Augmentation
involves the addition of a second agent that is not routinely regarded
as an antidepressant. Joffe, 1995:7 (4); Joffe, 1996:26 (5)
Electroconvulsive
therapy (ECT)
- ECT is the most
effective treatment for psychotic depression and severe depression
(eg, patients at risk of suicide, elderly patients unable to tolerate
medications). Phillips, 1994:23 (13)
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