Antidepressants: Treatment Failure

Treatment Failure

Failure to respond to treatment is most often due to inadequate treatment rather than “true” nonresponse. Inadequate treatment can be due to an inadequate length of treatment or an inadequate dose. These can result from the physician’s error (either improper dosing strategies or impatience in waiting an appropriate amount of time) or the patient’s error (through misunderstanding or nonadherence).

Patients will often not acknowledge nonadherence as they fear rejection from treatment, and they are certainly unlikely to ad-mit to it if their physician does not ask them. The best remedy for nonadherence is prevention, through proper education of the patient about likely side effects that might otherwise unnerve the patient. A flexible approach is also necessary. Gentle reassurance and encour-agement can be helpful; however, dogmatic insistence on adherence to a prescription leaves the patient with no choice except to hide nonadherence, or look elsewhere for treatment.

Thus, “true” nonresponse can be defined as the lack of response to an adequate dose for an adequate time. Many strategies have been suggested for treatment-resistant patients. Electroconvulsive therapy offers a safe, effective alternative somatic therapy for depression. A prior good response to electroconvulsive therapy, a need for rapid response as with life-threatening depressive symptoms (food refusal, suicide attempts) or a medical contraindication to antidepressants warrants early consideration of this treatment. It should be considered for any patient with major depression who has not responded to antidepressant medication.