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What to Do When Antidepressants Don't Work: Taking Next Steps
Erika Krull, MSEd, LMHP
Treatment for depression often begins with being prescribed an antidepressant. There are lots of choices for antidepressants, with different classes all designed to work on different neurotransmitters, or chemicals in the brain. Yet despite this variety, about one in three people
don't respond to antidepressants.
If you've tried a few different antidepressants but seen no results, you may feel like giving up. But there's always hope for finding a treatment that works. If you're not sure what to do when antidepressants don't work for you, this article will provide an overview of the medication options available, the non-drug treatments for depression, and what to consider when making a change.
Understanding Common Antidepressants
Scientists have designed antidepressants to work with certain neurotransmitters, which are chemicals in the brain that carry messages through your nervous system. Each
medication class targets a specific neurotransmitter to help improve your mood.
The most commonly prescribed class is selective serotonin reuptake inhibitors (SSRIs), which work with the neurotransmitter called serotonin. That said, there are several classes that all target slightly different combinations of neurotransmitters. If your antidepressant medication isn't working, your doctor's first step will likely be switching antidepressants to see if targeting a different set of neurotransmitters is more effective.
Another route your doctor may try is prescribing a combination of medications. This may be a good option if you aren't getting enough relief from a single antidepressant, especially if you've been taking it for several months. If you have chronic depression or some severe symptoms, a
combination treatment might be helpful for you.
This could mean using two antidepressants at the same time, or you could take an antidepressant along with a different medication. This approach is often called an augmented treatment. As an example, antidepressants can make bipolar depression symptoms worse when used alone, but they're more likely to be effective when paired with a mood stabilizer. Anti-psychotic medication can also be used with antidepressants, and this
combination can help some people who see little improvement after trying several treatments.
The use of combination treatments has become more common in the last two decades. A report from 2018 showed that approximately 60% of people who didn't get enough relief with one antidepressant were prescribed a combination of medications. In 1996, more than a million of all people estimated to have depression were using a combination treatment. By 2015, that number had grown to nearly 5 million.
How Many Antidepressants Will You Need to Try?
Some people who try antidepressants get relief on their first try. But those who don't feel better right away may try three or four medications before they find one that works. Some trial and error is common, but it can be a discouraging process.
If you've struggled in your search for an antidepressant that works, you're not alone. The success rate for finding an effective antidepressant on the first try is approximately 70%, meaning about one in three people don't. If you don't feel better after six to eight weeks, you may be asked to try another one. It's important to note that
each consecutive change in medication is less likely to work than the one before. That said, many have seen their symptoms improve after trying several types or combinations of antidepressants.
When to Look for Non-Medication Treatments
Although antidepressants are an effective treatment, they do not work for everyone. It may be time for you to start looking into other options when:
- Your symptoms haven't improved after trying at least two antidepressants, taking each one as prescribed for at least six to eight weeks.
- You're experiencing side effects that are impacting your weight, sleep, libido, or are otherwise lowering your quality of life.
If either of these factors are the case, you may have
treatment-resistant depression (TRD), meaning medication has limited benefits for you. If you suspect you have TRD, switching to a non-medication treatment may be more effective.
Before making changes to your medication, help your doctor understand your symptoms and how you feel. Making a change on your own can be dangerous, so you'll want to schedule an appointment to discuss your options if you're considering stopping or switching antidepressants.
A non-medication treatment like Transcranial Magnetic Stimulation (TMS) may be an option for you.
TMS therapy uses magnetic pulses to target specific areas of the brain that regulate emotions. If antidepressants aren't working for you, TMS might be a more effective treatment to diminish your symptoms because it's a non-drug option and does not have drug-related side effects.
Considering a Treatment Change
If you've had trouble finding the right treatment, and you feel stuck wondering what to do when antidepressants don't work, remember you have more options than you might think. It's okay to make a change—you deserve a treatment plan that works for you. If your antidepressants aren't working as well as you'd like, we're here to help.
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Starting any medical treatment for the first time can leave you with questions, especially if you’re looking forward to the benefits it may bring. It’s no different when you’re preparing for your nasal esketamine treatment. Your previous mental health treatments may have consisted solely of taking antidepressants at home or visiting a therapist’s office for cognitive behavioral therapy (CBT), so nasal esketamine is probably a new treatment experience for you. If you're wondering what it's like to start nasal esketamine and get ready for your first session, keep reading. Getting Started with the Nasal Esketamine Treatment As with any new treatment, you’ll first talk to your primary care provider or psychiatrist about whether nasal esketamine is a good fit for you. Alternatively, you can schedule your esketamine nasal spray consultation with a treatment center (such as Greenbrook) that has certification by the FDA’s Risk Evaluation and Mitigation Strategy (REMS). At Greenbrook's REMS-certified nasal esketamine treatment centers, our Greenbrook-affiliated psychiatrists and psychiatric nurse practitioners will review your medical history and also conduct our own assessment to help determine whether nasal esketamine treatment is right for you. Certain conditions, including blood vessel disease and a history of psychosis, may make treatment a risk for you. Make sure you discuss all previous and present conditions with your doctor or nasal esketamine provider before beginning treatment. If the medication is deemed a good fit, you’ll receive your prescription from the Greenbrook-affiliated provider. Your Greenbrook Care Team will put together a personalized care plan for the weeks and months to follow. Keep in mind that you will need to take a standard (oral) antidepressant along with your nasal esketamine treatment. There are two important regulations to note when it comes to preparing for treatment: Each treatment is followed by a mandatory two-hour observation period. This means you will need to plan to stay at the center for at least two hours following your self-administration of the esketamine nasal spray. You cannot drive during the rest of the day after treatment and must arrange for transportation. These regulations are mandatory. It may be helpful to sit down and plan out several weeks’ worth of transportation once you know your treatment schedule. In addition, if you’re wondering what to bring for the treatment, we recommend entertainment such as an audiobook or playlist of favorite songs and a pair of headphones. You may want them during the two-hour observation period. What to Expect During Nasal Esketamine Treatment On the day of treatment, you’ll need to stop eating any food two hours before your appointment and stop drinking all fluids 30 minutes before you come in. Your Greenbrook Care Team will confirm that you are prepared for the two-hour observation period and that you have a ride home. You’ll get the opportunity to practice using a “trainer sprayer” that mimics the real nasal esketamine sprayer but does not release any medication. The Care Team will encourage you to use the restroom and set up your preferred environment in your private treatment bay or room. Some patients like reduced lighting, for example, while others don’t request light adjustments. You’ll complete a depression scale before each treatment session. Your Greenbrook provider will confirm that the dose kit is yours, show you how to administer it, and then hand it to you. Each sprayer contained 28mg of Spravato esketamine nasal spray. Patients usually start with two sprayers (56mg) and soon increase to 84mg (three sprayers) per treatment. But, your dosage maybe vary. Should you be left with a metallic taste by the spray, the Care Team will offer suckers to help make the flavor dissipate. After your dose, you’ll be encouraged to lie back in your comfortable recliner. While most patients enjoy a quiet setting, Greenbrook is prepared to accommodate patients with a more animated reaction to the medication. You may feel sleepy, dizzy, mildly dissociated, and/or nauseated during treatment. Greenbrook's Care Team is readily available if you need assistance. How to Prepare for after your Nasal Esketamine Treatment Most side effects begin to wane in the second hour of observation, but if you’re wondering, “Is it safe to drive immediately after nasal esketamine treatment?” the answer is a resounding no. In addition to the mandatory ride home, you will need to block off time to rest and let side effects fully dissipate. This extended rest period is especially important in the first weeks of treatment when you’ll have treatment twice a week. Do not drive or operate machinery of any kind until the day after treatment. Just take it easy, relax, and take care of yourself. If you’re unsure what activities you can do or should avoid during this time, talk to your Care Team for more information. While side effects tend to dissipate completely after a good night’s sleep, many nasal esketamine patients begin feeling relief from depression symptoms within hours of their treatment. Other Tips in Preparing for Your Nasal Esketamine Treatment At Greenbrook, we make every effort to schedule your treatment in the afternoons or whenever it is most convenient for you. We encourage you to see each treatment session as an opportunity to relax and take care of your mental health. If you have any questions or concerns, talk to your doctor or the Greenbrook Care Team. At Greenbrook, we’ll help you feel at ease when preparing for each treatment session. Schedule A Free Consultation To get started with nasal esketamine, schedule your free consultation today.
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