My Antidepressant Is Not Helping. What Happens Next?

One of the most difficult aspects of treatment is the long period of trial and error to find the right types of medications and the right doses to treat my daughter’s bipolar disorder effectively. It has taken almost 2 years to reach a point where she is relatively stable and not experiencing wild mood swings. Patience and perseverance have been part of the prescription, and the result is that she has been able to resume her life at college.

You have to talk to your doctor. If feeling discouraged, consult with your doctor, as there are so many other choices to consider. My doctor changed my medication and said if it too doesn't work, we will try something else.

It can be disheartening when you do not feel better after a medication has been started. The pharmaceutical companies advertise their antidepressant medications in ways that suggest almost “miraculous” recovery.

The reality is that the response rate to any given anti-depressant tends to be approximately 60% to 70% in clinical trials.This means a good portion of individuals (more than 30%!) would not be expected to see improvement on the first medication tried. However, if a medication is not working, several factors first need to be considered: How long has the medicine been taken? Is the dose high enough? Is the medication being taken as prescribed?

It takes from 4 to 6 weeks (sometimes up to 8 weeks) for the full effect of an antidepressant to take place (after an adequate dose has been prescribed). Often, the dose of medication has not been optimized.

As long as there are few or tolerable side effects, the dose can be pushed to the maximum recommended dosage (see Appendix B). Your doctor may want to go past the typical maximum dose if you have no side effects and have partially responded to the treatment.

However, in general, once the maximum dose has been prescribed for up to 6 weeks and you have been taking it as prescribed, an adequate medication trial has occurred. If there is no improvement, a switch to another medication should be made. The change can even be within a class; for example, a lack of response to one SSRI does not mean the same will be true for another SSRI.

If there is a partial response, yourdoctor may want to augment with another medication. Aug-mentation strategies generally involve using a medication with a different mechanism of action so that different neurotransmitter systems can come into play to help, similar to what cardiologists do when they prescribe antihypertensivemedication to patients whose blood pressure remains elevated after an initial antihypertensive has been prescribed.

Thus if treatment with a given agent fails, management techniques include switches within a class, switches to another class, augmentation, the use of medications other than antidepressants, andelectroconvulsive therapy for more refractorydepression.

It is very important to be open with your doctor about your level of compliance with a given medication. It is not unusual for people to forget doses or skip doses for specific reasons. People often do not want to admit this to their doctor, because they believe he or she will become upset with them.

If you are having problems taking your medication, it is extremely important for your doctor to know so that the two of you can discuss some of the barriers to taking it, such as side effects. A lack of efficacy is often due to regularly missed doses, and without this knowledge, other medications trials may be suggested unnecessarily.