If you and your doctor are not satisfied with the amount of improvement you've had while on an antidepressant, you're not alone. In a three-month study of 4,000 depression patients, at least half didn't get complete relief from the first antidepressant they tried.
Doctors talk about a "response" to an antidepressant, which means at least some improvement, and "remission," which means that the symptoms go away altogether. For most people, remission is a realistic goal. If one antidepressant doesn't do the trick, your doctor may consider the following options.
- Increasing the dose of the antidepressant you're on
- Continuing at the same dose and adding a second drug: either another antidepressant (combination therapy) or add another type of drug (augmentation therapy)
- Switching, which involves gradually stopping the first drug and starting a second
- Starting psychotherapy, if you're not already attending sessions
When to switch antidepressants
"My hope for every patient is that major depression remits as soon as possible with few side effects," says George I. Papakostas, MD, an assistant professor of psychiatry at Harvard Medical School.
The three factors listed below go into his decision to call it quits with a particular drug or to continue using it and add something else.
- Tolerability: How severe are the side effects, and how much trouble are they causing?
- Time: How long have you been on medication?
- Degree of improvement: Have the depression symptoms improved in proportion to how long you've been on medication?
If you've had only a slight improvement in symptoms but the side effects are burdensome, your doctor will switch you to something else altogether. Your doctor may also recommend a total switch if you're experiencing little or no improvement, even if side effects aren't a problem.
Dr. Papakostas says most psychiatrists agree that if an SSRI hasn't worked for you, switching to an atypical antidepressantWellbutrin, Cymbalta, Remeron, or Effexormay be a good idea.
Higher doses of antidepressants
If you're doing well with an antidepressant but there's room for improvement, increasing the dosage may be a smart move, especially if you're not experiencing side effects. If you don't notice a significant response after six weeks at a higher dosage, switching to another antidepressant is probably the most appropriate therapeutic intervention, says Kenneth Robbins, MD, clinical associate professor of psychiatry at the University of Wisconsin–Madison.
Adding another drug to the one you're already taking may also help.
Some of the medications doctors may prescribe include Wellbutrin, lithium, thyroid hormone, or Provigil.
Depending on a patient's exact diagnosis and tolerance for side effects, doctors sometimes prescribe an atypical antipsychotic, a class of drugs used in bipolar disorder and schizophrenia that includes olanzapine (Zyprexa), risperidone (Risperdal), clozapine (Clozaril), and quetiapine (Seroquel).
Mounting evidence suggests that these drugs may boost the effectiveness of antidepressants. Some of the drugs in this category, such as aripiprazole (Abilify) and quetiapine (Seroquel XR), have been approved as add-on treatments for people already taking antidepressants, whereas olanzapine (Zyprexa) is approved specifically for use in combination with fluoxetine (Prozac), which can be taken in a combo pill called Symbyax.
Doctors prescribe other atypical antipsychoticssuch as risperidone (Risperdal) and clozapine (Clozaril)off-label, meaning the U.S. Food and Drug Administration (FDA) has not approved the drugs for depression.
When not to quit antidepressants
Patients who want to stop taking antidepressants should do so gradually, with their doctor or psychologist's guidance. However, fear of suicidal tendencies and fear of addiction should not be factors.
News reports have linked antidepressant use to a higher risk of suicide, but the research actually shows the drugs may increase thoughts of suicide. No studies have linked the medications to the act itself. A far greater number of patients experience a decrease in thoughts of suicide. And only 1% to 4% of patientschildren and adultsappear to be at risk. "Of the patients we see, 30% to 40% have already thought about suicide before they even get treatment," says Maurizio Fava, MD, professor of psychiatry at Harvard Medical School. Dr. Papakostas says numbers like these suggest that getting proper treatment for depression is far more likely to prevent suicide attempts than increase them.
For people concerned about becoming dependent on antidepressants, relax. According to Dr. Papakostas, abruptly stopping antidepressants can result in discontinuation symptoms (such as nausea, insomnia, and agitation) for a week or two, but most patients are able to ease off the drugs gradually without suffering from withdrawal.