Steps to take for incomplete antidepressant response.(Clinical Rounds)

SAN FRANCISCO -- The goal of antidepressant treatment should be remission, but most clinical trials use a 50% response in 50% of patients as the criterion for effectiveness. Only about 20%-30% of patients achieve complete remission, and this suggests that additional treatment will be necessary, Jeffrey M. Levine, M.D., said at the annual meeting of the American College of Physicians.

But before changing a patient's selective serotonin reuptake inhibitor (SSRI) prescription because of an incomplete response, physicians should consider a series of questions, said Dr. Levine of the Albert Einstein College of Medicine, New York. First, determine whether the patient is taking the medication. Studies indicate about 50% of SSRI prescriptions are filled only once. Also, find out whether the patient is using alcohol or illicit drugs.

Next, use this as an opportunity to review relevant medical issues. Has the patient had recent thyroid function and HIV tests? Is she taking any other medications, such as glucocorticoids, [beta]-blockers, or fluoroquinolones that could affect depression treatment? Has the patient been evaluated for sleep apnea?

It may be productive to employ the systematic approach suggested by the mnemonic CITTENNS for possible causes of altered mental status. CITTENNS stands for cardiorespiratory, infectious, toxic, traumatic, endocrine/metabolic, neurologic, neoplastic, and systemic/autoimmune.

Ask about domestic violence, safety issues, or threats to the patient. "If a patient is being abused or threatened by a partner, your antidepressants are not going to make [her] better," Dr. Levine said.

Consider whether the patient may have something to gain from depression. "If a patient has a comp case or a disability case going at this moment, it may be irrelevant ...