Treatment Resistant Depression

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Stepped Treatment of Depression
1. Start with your favorite SSRI

Push dose at 1 month if no better

Initial Next Step Max___

Citalopram (Celexa) 20 mg/d 30 mg/d 40 mg/d

Fluoxetine (Prozac) 20 mg/d 40 mg/d 80 mg/d

Paroxetine (Paxil) 20 mg/d 40 mg/d 50 mg/d

Sertraline (Zoloft) 50 mg/d 100 mg/d 200 mg/d

Escitalopram (Lexapro) 10 mg/d 20 mg/d 30 mg/d

After maximizing dosage of initial
2. Augment with one of the following if not in remission in 2 months.

Bupropion SR (Wellbutrin SR)

Add 150 mg qd for week 1

Increase to 150 mg bid for weeks 2,3,4,5

Increase to 200 mg bid starting week 6 if needed

T3 (Cytomel)

Start 25 µg/d for weeks 1, 2

Increase to 50 µg/d

Cognitive therapy
Switch (no taper of previous SSRI) if not in remission in 2 months

Other SSRI

Venlafaxine XR (Effexor)

37.5 mg/d for week 1

75 mg/d for week 2

` 150 mg for week 3, 4, 5

225 mg for week 6 if needed

Bupropion SR (Wellbutrin SR)

Start 150 mg qd for week 1

Increase to 150 mg bid for weeks 2,3,4,5

Increase to 200 mg bid starting week 6 if needed
Cognitive therapy

3. If not in remission in 4 months consider new augmentation or consultation

Questions to help understand why the patient’s depression did not respond

to my treatment

  1. Is the person taking the medication as prescribed?

  1. Have I waited long enough?

Research suggests that half of the patients who ultimately are in remission by Week 12 will report only limited response by Week 6.

  1. Did I get the diagnosis right?

Antidepressants treat depression. Unfortunately we can confuse substance abuse, personality disorders, medical disorders, bipolar disorder, psychosocial distress, adjustment reaction, grief, and burn out for depression.

  1. Do I have the right dose of medication?

There is some evidence, and wider acceptance, that higher doses of SSRIs are associated with a higher response rate.

  1. Am I using the right medication?

While all SSRIs seem to have the same response rates, the failure of the first SSRI does not mean another SSRI will not be effective.
Directory: familymedicine

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