Most depression labelled resistant has not been adequately treated. Three questions settle it faster than any augmentation strategy.
What dose, for how long? An antidepressant started at a low dose and never titrated is a trial that did not happen. Six to eight weeks at a therapeutic dose is the minimum before calling a drug a failure, and a patient who improved slightly at four weeks needs more time, not a different molecule.
How many days were actually taken? Ask for the last dose taken and the number of missed days in the past fortnight, not whether the patient is taking the tablets. And ask what else is going in: alcohol, benzodiazepines bought without prescription, and steroids or isotretinoin are all common and all change the picture. Check thyroid function and haemoglobin, and in an older patient consider whether this is depression at all.
Only when dose, duration, adherence and mimics are all excluded does the word resistant mean anything - and by then a good proportion of these patients have improved.
- Confirm the dose reached and the weeks completed before declaring any antidepressant a failure.
- Ask for the last dose taken and missed days, never whether the patient is compliant.
- Take an alcohol and over-the-counter medication history at every review, not just at intake.
- Check thyroid function and haemoglobin before escalating treatment.
- In an older patient, reconsider the diagnosis before adding a second drug.
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