When the meds aren’t working


Dr. Robert McMullen talks about treatment with antidepressants and why sometimes they don’t work as well as hoped.

He states sometimes treatment may need combining of one antidepressant with another. He does believe we should not try to switch antidepressants too often. Admittedly, there is debate in the medical community about of changing antidepressants too often affects the clinical course. However, it can be also argued that it is more a matter of treating a more treatment resistant/ill patient population and not due to the medication itself. If there is a partial response, many psychiatrists would recommend pursuing augmentation, such as sertraline (Zoloft) with bupropion (Wellbutrin), this combination had the nickname of Welloft. Generally, the two antidepressants tend to be from different classes like in that example. Now, if despite using an SSRI/SNRI with augmentation has not worked well, a different class of medication are know as the monoamine oxidase inhibitors (MAOIs). They are still known as some of the most powerful antidepressants. Sometimes MAOIs especially have a higher chance of working well in those who have atypical symptoms depression. This is characterized by excessive sleeping, eating, feeling very heavy, and sometimes excruciating sensitivity to rejection or perceived rejection.

Another factor that can be involved in insufficient response to medication is if there is an element of bipolar disorder. Along with the lows, they can have periods where they feel the opposite. They get over enthused, are overactive, need a lot less sleep, maybe get impulsive and sometimes their self esteem is overflated. If this is the case, there are different approaches various providers have taken. Some start with a clean slate, and discontinue all the medications. And/or there may be introduction of agents used for bipolar depression such as various mood stablizers (e.g. lamotrigine aka Lamictal, lithium) or neuroleptics/antipsychotics (e.g. lurasidone aka Latuda, quetiapine aka Seroquel).

Medical factors may also be involved. These can include a low vitamin B12 level or hypothyroidism to name a few but the many possibilities. Sometimes the TSH can still be in the normal range but be slightly over 2.5. In such cases, sometimes T3 can be added as an augmenting strategy and potentially more helpful. Some patients may also struggle with metabolizing folate into the biologically active form to cross the blood brain barrier and in these cases, supplementing with l-methylfolate can be of help.

And of course, we should not underestimate the benefits of generous exercise and socialization being important ingredients to a patient’s recovery. Nutrients are also very important, so food items rich in omega-3 fatty acids such as fish, spinach, tofu and fortified eggs and milk remain high on the recommended list. Not to mention the cardiovascular protective factors of these dietary changes.

Other treatment modalities can be explored, which include neuromodulation. Transcranial magnetic stimulation (TMS) has a high proportion of responders. Vagus nerve stimulation and electroconvulsive therapy are also options.

Ironically, sometimes the treatment approach involves continuing to take the medication for a longer time. Sometimes in the magnitude of months or up to a year. There are reports of patients who utilized this approach and ultimately experienced full and sustained relief!