Thursday, January 15, 2009
Your life isn't going right. Your doctor diagnoses you with clinical depression and prescribes an antidepressant. The antidepressant doesn't work or partially works or makes you feel worse. What now?
The American Psychiatric Association in its 2000 Practice Guideline for treating depression suggests going with a different antidepressant. This recommendation is backed up by the NIMH-underwritten STAR*D clinical trial results of 2006.
Fine, but what about if your second antidepressant fails? The APA recommends keep trying, but STAR*D shows the success rates drop off dramatically at this stage. What gives?
For one, it may be time to revisit the diagnosis. Psychiatric treatment guidelines are based on the fallacy that your doctor has nailed your diagnosis on the first try. But, more commonly, those of us with bipolar tend to first get misdiagnosed with depression.
Even those correctly diagnosed with depression may be out of luck. Psychiatry tends to treat all depressions as alike, with one-size-fits-all antidepressants. There is, for instance, a clear distinction between chronic and recurrent depression, and a body of expert opinion that says antidepressants may be problematic for the latter.
This distinction is way too subtle for your average psychiatrist. But eventually they may wise up and try a bipolar diagnosis and prescribe a mood stabilizer (or antipsychotic). But what if a series of trials on mood stabilizers fail? Or only yields partial results? What now?
Way too many of us are struggling. Check out the poll at the top left corner of this page. At the time of writing this, of 58 people who have responded so far, 25 say they are stable but not well and 12 that they're in crisis or close to crisis. Only eight are where they want to be or feel better than they ever could have imagined.
This is where the frustrated clinician often starts blaming the patient. The meds are supposed to work. That pharm rep who looks like Heidi Klum said these meds work, and she wouldn't be lying, right? It has to be your fault.
Time to revisit the diagnosis? Again?
More in my next blog ...
Further reading from mcmanweb: When Your Second Antidepressant Fails