Augmentation Strategies As many as 50% of patients do not respond to initial antidepressant therapy. Primary strategies for nonresponders include
1) making sure that drug dosage is adequate and that the duration of therapy has been sufficiently long,
2) switching to another drug in the same class, and 3) switching to a drug from different class (e.g., from an SSRI to bupropion). Another option is to add another agent. Lithium augmentation has been well studied, with up to 60% of nonresponders reporting improvement within four weeks of initiating lithium therapy. When used in this manner, lithium dosage should remain in the subtherapeutic range. Low doses of thyroid hormone may be helpful in selected patients, although randomized controlled trials have shown equivocal results. The combination of an SSRI with bupropion, buspirone (an anxiolytic), or a tricyclic antidepressant is being used empirically but has not been well studied. Because SSRIs can inhibit metabolism of the tricyclics, patients receiving this combination should have blood levels of the tricyclic regularly monitored.Finally, it should be remembered that psychotherapy can often augment pharmacotherapy.
Antidepressant discontinuation syndrome is unrelated to relapse or recurrence and may appear following withdrawal (generally but not exclusively, abrupt withdrawal) of any class of antidepressant.
SSRI discontinuation syndrome occurs most commonly in patients receiving agents with a short half-life such as paroxetine. Manifestations include anxiety, irritability, flulike symptoms, dizziness, paresthesias, lethargy, insomnia, and vivid dreams or nightmares. Symptoms are usually mild and self-limited. Management options include temporarily reinstituting drug treatment, treating specific symptoms (e.g., sedatives for insomnia), switching to another agent that might be more easily tapered (e.g., from paroxetine to fluoxetine), or simple reassurance.
Psychotherapy and Other Nonmedical Approaches
For control of mild-to-moderate depression, psychotherapy—either cognitive or interpersonal—is generally regarded as comparable to drug treatment. It offers the theoretical advantage that risk of recurrence may decrease once patients recognize and learn to cope with the underlying problems that triggered their depression. Some studies have shown an additive benefit when psychotherapy and medication are used concurrently. (For treatment of severe depression, psychotherapy alone is not recommended.) Not every patient is willing to undertake psychotherapy or drugtreatment, however. For these patients, there are some simple recommendations that may improve function and mobilize the patient to seek further help. Regular exercise elevates mood and enhances body image. A list of pleasurable activities can be drawn up by the patient and subsequently prescribed by the physician to counteract anhedonia. Patients who have withdrawn from social activities can be assigned to attend a group event or arrange several lunches with friends before the next scheduled appointment. It may also be helpful for patients to keep a week-long mood diary, noting any cognitive distortions (such as seeing events as either black or white, or seeing a single negative event as indicative of general failure) that occur with onset of depressive moods. Once patients become aware of the self-punishing nature of these thoughts, they can learn to replace them with more positive, self-affirming thoughts.
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