Before I see them, most of my depressed patients have failed an SSRI trial prescribed by their primary care physicians. Some have already tried two or more antidepressants. I bet your practice is the same.
Unfortunately, few medications have been tested on patients with treatment-resistant depression. To gain FDA approval, an investigational drug needs to show a treatment effect greater than placebo, and testing a drug on a treatment-resistant population is risky for pharmaceutical companies. Compared with monotherapy, even fewer large-scale studies have combined two or more medications for major depressive disorder.
In this issue, A. John Rush, MD, of the University of Texas Southwestern Medical Center, provides the best synthesis I have seen of the literature on treatment-resistant depression. I am already incorporating his insights into my clinical practice.
Not to minimize the suffering of patients with treatment-resistant depression, but I believe this disorder saved psychiatry. Ten years ago, doomsayers predicted psychiatry’s demise, assuming anyone could do psychotherapy and any physician could prescribe 20 mg of Prozac. Those predictions have proven wrong, and demand for psychiatrists has grown.
We do not compete with primary care physicians. The more depressed patients our medical colleagues treat, the more treatment-resistant cases they refer for psychiatric care. We may not be seeing as many patients with nontreatment depression, but fewer with major depressive disorder are suffering without receiving effective treatment.