THE BLOG
08/06/2013 05:37 pm ET Updated Oct 06, 2013

Depressed? Treatment Not Working? Be Careful What You Do Next

If you are taking an anti-depressant but are still depressed, the ad says, ask your doctor about adding Abilify (originally approved as an anti-psychotic medication). This is, at best, misleading medical advice. It implies (even if it doesn't say it directly) that adding Abilify should be the first course of action if your anti-depressant isn't lifting your mood adequately. In fact, there are usually preferable alternatives that should be tried first.

I am not suggesting that Abilify cannot be a useful treatment for depression. The Federal Drug Administration (FDA) approves the use of Abilify in combination with an anti-depressant to reduce depression. (1) But all that means is that it is safe enough despite its possible side effects -- many of which are listed hurriedly in the ad -- and that it is effective enough, since it works for a higher percentage of people than a placebo or certain other atypical antipsychotic medications do, to be a drug that doctors are allowed to prescribe. Whether they should is another question. And the answer is sometimes yes, but rarely right away.

But, you might wonder, if it is a possibly helpful form of treatment, what's wrong with the ad telling people to ask their doctors about it?

The unfortunate fact is that, if you are being treated for depression by a doctor who is not a mental health professional -- a primary care physician, a cardiologist, an oncologist, etc. -- the chances are that your doctor has very limited experience regarding major depressive disorder (MDD). The major psychiatric epidemiological study in the U.S. -- the National Co-Morbidity Survey Replication (NCS-R) -- indicates that physicians who are not mental health professionals fail to meet the survey's standards for "minimally adequate treatment" over 85 percent of the time (2). So a discussion with such a doctor about the advisability of adding Abilify may not result in a well-informed decision.

Better advice would be to suggest that a person who is not responding adequately to an anti-depressant seek treatment from a qualified mental health professional. It is true, according to the same study, that mental health professionals fail to provide minimally adequate treatment about 50 percent of the time. Still, that's a lot better than inadequate treatment 85 percent of the time.

Unfortunately, well-qualified mental health professionals are hard to find in many parts of the United States, and, even in areas of the country where they are available, many people do not follow up on referrals to them, making it critical for medical practices to increase their competence regarding mental health.

What would a well-informed physician do? The usual course of action -- based on the fact that not all anti-depressants are the same and that some work for some people some of the time while others work for others -- is to try a different anti-depressant, not to continue the one that isn't working and add Abilify (3). So you should first ask your doctor about alternative anti-depressants before asking about Abilify.

More importantly, it is not at all clear that the response to the failure of an anti-depressant to produce a significant improvement in mood should only be to modify drug therapy. There are other effective ways (and possibly more effective) ways to treat "mild" or "moderate" major depressive disorder (MDD), for which anti-depressants may not be effective at all (4).

One evidence-based alternative is psychotherapy, including cognitive behavioral therapy (5), interpersonal therapy (6), behavioral activation therapy (7), and others. Some research suggests that combining anti-depressants with psychotherapy is more effective for most people than anti-depressants alone. (8)

In addition, it is reasonably clear that being active and connected with other people is a great antidote to depression. In fact, there is a vicious cycle at work: Depression makes people less active and more isolated, inactivity and isolation increase depression, and so on. The trick is to interrupt the cycle by pushing yourself to do something that gives you some satisfaction and/or to spend time with people you might like being with. Some people may be too depressed to push themselves at all, but many people who are depressed can take actions that will break the cycle, especially with encouragement and support from someone they trust such as their doctor.

Finally, it may be that persistent profound sadness and/or lack of interest in life's potential pleasures is the result of life circumstances rather than a personal, internal illness. Loss of people you love can have a terrible emotional impact, as can being unemployed, living in profound poverty, being powerless, living in dangerous circumstances, etc. It is simply not clear that the right response to all people who are suffering emotionally is to diagnose them with, and treat them for, a mental disorder. Helping people to escape from dreadful circumstances and social action to change the conditions they live in may do far more than mental health services to reduce depression in the long run -- not that they are mutually exclusive.

Are you depressed, not just sad (as all human beings are from time-to-time) but deeply depressed? Don't ignore it. Try to get help. And, keep in mind that there are alternatives to adding an anti-psychotic medication when the first medication you try is not working well enough.

For help with any emotional distress, call the NATIONAL SUICIDE PREVENTION LIFELINE at 1-800-273-TALK (8255)

References:

(1) Nelson, J. Craig et al. "Augmentation treatment in major depressive disorder: focus on aripiprazole" in Neuropsychiatric Disease and Treatment. October, 2008.

(2) Wang, Phillip, et al. "Twelve-Month Use of Mental Health Services in the United States: Results From the National Comorbidity Survey Replication" in Archives of General Psychiatry. June 2005.

(3) Wright, B. et al. "Augmentation with atypical antipsychotics for depression: a review of evidence‐based support from the medical literature." Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. March 2013.

(4) Fournier, J. C., et al. "Antidepressant drug effects and depression severity: A patient-level meta-analysis". Journal of the American Medical Association. January 2010.

(5) NREPP: SAMHSA's Registry of Evidence Based Practices. "Cognitive Behavioral Therapy for Depression and Anxiety Disorders".

(6) Cuijpers, P. et al. "Interpersonal Psychotherapy for Depression: A Meta-Analysis" in American Journal of Psychiatry. January 2011.

(7) Dimidjian, S., et al. "Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression". Journal of Consulting and Clinical Psychology. August 2006

(8) Hollon, SD et al. "Psychotherapy and medication in the treatment of adult and geriatric depression: which monotherapy or combined treatment?" in Journal of Clinical Psychiatry. April 2005.

For more by Michael Friedman, LMSW, click here.

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