Michael Thase, MD, on Addressing Ineffective Antidepressant Treatment
Michael Thase, MD, discusses the most important steps for clinicians to take when a first-line antidepressant is not effective and guidelines that can help them decide whether to discontinue an ineffective antidepressant or augment it with an adjunctive therapy.
Dr. Thase is Professor of Psychiatry, Perelman School of Medicine, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.
When your first choice of medication hasn't helped a patient, you have the opportunity to take another look at a few things that are involved even in the initial decision to prescribe. Did you make the diagnosis correctly? Are there other conditions that might be complicating that need to be paid attention to? Importantly, has the patient taking the medicine?
It turns out that, in some practice settings, 10% of patients don't even fill that first prescription. Sometimes they don't tell their doctor they've not done it. They come for the follow‑up visit and conceal that they've not even taken the medicine.
More often, the patient has an inconsistent adherence to the dosing. We know that anything less than 80% of the doses, or less than 6 out of 7 days a week, and you're likely not to get their desired result. So make sure that the diagnosis was right, the patient's taking the medication, and that if there are side effects, that you're addressing those side effects.
When the first treatment works, or any subsequent treatment, that is one of the essential questions. Do I try to augment this medicine, or do I switch away from it? I think we prefer to switch when the first medication's poorly tolerated. We're at barely the minimum dose. There's no room to do the increase because when you do an adjunctive strategy, you're using that first medicine as a foundation to build on. If the foundation's not strong, why try to build on it?
I think that, if the first medicine has been somewhat helpful, and it's reasonably well tolerated, then picking an adjunctive strategy is a good thing, because you have a number that you know can work. You have a different range of possibilities that you can pick, some of which you can select a target for particular symptoms, like persistent insomnia or significant anxiety. You can target the treatment to match what the patient needs the most in order to feel better.
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