What alternatives to first-line therapy for depression are effective?

Abstract

Depression is often a chronic illness that requires a methodical, long-term approach to manage it optimally. A single antidepressant trial is often insufficient for patients to achieve remission. Remission rates for selective serotonin reuptake inhibitors are about 30% to 35%. Using successive treatment steps with optimal medication dosing and making measurement-based treatment decisions can help patients achieve remission, but, at each step, remission is less likely than at the first step. Depression is considered treatment-resistant if 2 adequate trials of medication fail. Clinicians can use validated symptom checklists such as the 16-Item Quick Inventory of Depressive Symptomatology, 9-Item Patient Health Questionnaire, Global Assessment of Functioning, and Sheehan Disability Scale to identify patients with treatment-resistant depression. Treatment resistance is likely in patients with a history of depressive chronicity and concurrent psychiatric and medical disorders and may be mistakenly suspected in patients who have had an inadequate trial of medication or who have been misdiagnosed. Strategies that can be effective to combat treatment resistance include optimizing treatment, switching to another antidepressant, combining antidepressants, and augmenting antidepressants with nonantidepressant treatments such as buspirone, lithium, liothyronine, atypical antipsychotics, or other agents. In addition, clinicians need to cultivate strong therapeutic alliances with patients, use objective measurements, practice evidence-based medicine, and educate patients about the disease and its treatments.