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Ask the Mental Health Expert Archives 2001-2004

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Lengthy Depression

Q. Three years ago I recovered from my second bout of depression (that lasted 7 months) with a combination of remeron, serzone, and effexor. I stopped antidepressant therapy after I became well. I had 3 symptom-free years but I became depressed again 7 weeks ago and have been on remeron (45 mg) and trazodone (150 mg) for over one month but have not yet felt relief from my symptoms. Should I go back on the same combination that got me through the last bout? What will help me long-term?

A. First of all, I hope you realize that without having assessed you, I'm not in a position to recommend specific treatments. That said, here are some ideas and directions to consider in consultation with your doctor. First, serious depression takes time to treat. Not everybody will respond within a month, even with appropriate and vigorous pharmacotherapy. For many patients, it may take 6-9 weeks before a full response to medication is achieved. So--I wouldn't give up the ship after 4-5 weeks, even though to you, it may feel like forever.

On the other hand, most patients, after one month, should notice at least a bit of improvement, even if only in their sleep--which raises the question of whether some new factor (medical, psychological, etc.) might be interfering with a full response. As a general rule, responses to medication tend to run true; that is, if a particular regimen got the patient better in the past, it's probably got the best shot at getting him or her better now.

Unfortunately, for some patients, depression tends to become more refractory over the years, for reasons we don't completely understand; and for some, it appears that their response to medication diminishes over the years. These problems can often be overcome by using a higher dose of the original agent, by augmenting with other medications; or by switching to a different type of agent. But, there's no easy way to predict which strategy will work best with a given patient.

If your current regimen doesn't produce some improvement over the next 2-3 weeks, one option would be simply to try increasing the dose of one or both antidepressants, if there are no medical factors that would make this unwise. For example, there have been refractory cases of depression that have responded to 60 mg/day of mirtazapine [Remeron]. Certainly, if that strategy did not work or were not feasible, I would consider trying the combination that got you better in the past, even though the potential for drug-drug interactions must be carefully considered when two or more antidepressants are combined.

There are many, many other options for refractory depression, so don't despair even if the original formula doesn't work. One thing I would strongly consider: many psychiatrists (including myself) believe that for folks who have had three or more bouts of serious depression, life-long maintenance on medication is the best route to go (Dr. John Greden calls this, "Three strikes and you're on.") This is because, unfortunately, major depression tends to be a recurrent illness, and the odds are much better that you will avoid another bout if you stay on medication indefinitely.

By the way, you don't mention whether or not you are also involved in psychotherapy--if not, I would strongly recommend you discuss that option with your doctor, since psychotherapy and medication usually work better together than either does alone. Cognitive-Behavioral Therapy (CBT) has a particularly strong track record. I wish you a (relatively) speedy recovery.

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October 2001

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