Depression can be a frustrating illness. Since the introduction of the first antidepressant medications more than 50 years ago, the process of finding the right medication to treat it has been one of trial and error. Given that it takes two to four weeks to have a good sense of whether a particular antidepressant will work, it can take several months to systematically assess a series of antidepressants in order to find one that's effective.
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After two or three trials that can take two to three months, most people become discouraged if they're still struggling with the symptoms of depression. The idea of trying a fourth or a fifth or even a sixth medication can seem like too much of a hassle. However, if one steps back from this disappointment, it's reassuring to remember that there are 18 different antidepressants currently available and prescribed. Many of the older ones are rarely used, but they can prove to be effective for a particular person.
Most people with severe treatment resistant-depression give up long before trying all of the available medications. That's why doing research to find a way to more efficiently identify the right drug for the right person at the right dose is so important.
In reviewing recent comments, it's clear that many of you who are treated with antidepressants and faithfully take your medication often have a good response that is followed by a relapse. Often the relapse occurs when you're experiencing increased stress and are feeling the most vulnerable. Your comments reflect the importance of staying in close communication with your physician. It also makes good sense to have a medical checkup at the time of a relapse as many medical and neurological illnesses can cause depression.
Once a medical cause for a relapse is ruled out, a sensible response is to consider raising the dose of the medication. Unfortunately, this is often done blindly based on the belief that it's not problematic to carefully push the dose up.
However, there are two strategies that a physician can use to minimize the risk of making things worse by escalating the dose. The old-fashioned way to do this is to get a blood level to check to see if there is the right amount of medication in the blood. Twenty years ago when the tricyclic antidepressants were popular, psychiatrists would routinely check the blood levels of amitriptyline (Elavil) or imipramine (Tofranil) before increasing the dose. In many places in Europe, psychiatrists still do monitor blood levels, but it's now relatively uncommon in the United States.
Today there's a more efficient method that can minimize problems that occur after increasing the dose. It's now possible to collect DNA by just rubbing a "cheek swab" on the inner surface of the cheek. The swab is then sent to a laboratory to determine your genetic metabolic capacity.
There are many examples of how this can help. One example is the use of paroxetine (Paxil). The usual starting dose is 20 mg, which may work well if you have a relatively low metabolic capacity because you'd have a quite high blood level at this starting dose. However, if depressive symptoms return, raising the dose to 30 mg will probably result in a very high blood level because you'd be unable to efficiently metabolize the medication. A blood level that's too high usually results in unpleasant side effects. In contrast, if you have a normal metabolic capacity you'd be unlikely to have severe side effects when the dose was increased by only 10 mg.
Many people feel like they've tried every antidepressant, but few have actually been prescribed 18 different medications. Of course, it's easy to be discouraged after even two or three failures, but persevering in the search for the right medication can pay off.
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