The first antidepressant didn't work. Now what?

Your child has tried their very first antidepressant. Hopes were high, but either they improved only a little or not at all…

Now what?

Recall the pie chart from my last post below showing how differently people respond to the same first antidepressant based on the STAR*D study.

So looking at the above chart, there was a 72% (yellow + red) that your child would improve a little bit, or not improve at all on their first ever antidepressant. 

During this time your child’s healthcare provider would have put your child on the medication in question for an adequate amount of time, at an adequate dose for it to have a ‘fair trial’ on their antidepressant.

What does adequate time and dose mean?

An adequate dose means that your child would have been taking the highest dose of the antidepressant that was tolerable, i.e. did not cause side effects, or caused side effects that they could handle comfortably. 

Adequate time means that they were consistently taking the medication as the healthcare provider prescribed, for a period of 8-12 weeks. The first 4 weeks is when you could see improvement in symptoms if it is actually going to work for your child, but more likely at the 6 week mark and beyond.

If both the above happened (adequate dose and time), then it was a ‘fair trial’ of the antidepressant.  This means that a good amount of effort was given, and the antidepressant did not work because it wasn't the right one for your child, not because the dose wasn't quite high enough, i.e. it was too weak, or because it didn't have enough time to kick in properly.

Typically it takes antidepressants 2-3 months to truly kick in because it takes time for changes in the brain to happen.

So then the question becomes, what do we do if the first antidepressant didn't work?

Let’s go back to the STAR*D study where the first antidepressant given was Celexa. 

Of the 72% who either didn't do well or sort of did well (red + yellow in the chart above), they were given the option to switch to a different antidepressant, like like Zoloft, Wellbutrin or Effexor, or stay on Celexa and add Wellbutrin or Buspar, another two antidepressants.  

Let's start with the number of people who chose to switch to a different medication.  

Here the number of people whose depression resolved with the new second antidepressant was 17%, 21% and 25% for Zoloft, Wellbutrin and Effexor respectively. On average, whichever second antidepressant was chosen, they worked really well for 21% people, and the depression went away.  

Put simply, every 2 in 10 who had not responded well to their first antidepressant, responded well to the second antidepressant, regardless of which one they chose.

Of the people who either didn't get better, or got a little bit better, but chose to stay on their first antidepressant, and then added either Wellbutrin or Buspar, 30% got better with Wellbutrin and the other 30% got better with Buspar. 

So 3 of 10 of the people who either had some improvement or no improvement on their first antidepressant and then added either Wellbutrin or Buspar to this first antidepressant, doesn't matter which, got better and the depression went away.

Again the above were at adequate doses (different for different people, but the highest dose they could tolerate without feeling lousy) and over an adequate amount of time (8-10 weeks). 

So, if your child tries an antidepressant for a few months and it doesn't work, or only works a little bit, then they can either switch to a different antidepressant completely or add another antidepressant to the original. Any of the two methods is worth trying. 

There is hope.

These results should be reassuring. It doesn't really matter which antidepressant is chosen second. There is no one superstar antidepressant that does so much better than the others in helping with symptoms.  The superstar antidepressant is going to be the one that works for your particular child, which is going to differ from the one their friend at school takes.

When working with your healthcare provider to choose the second antidepressant (whether you are switching to it completely or just adding it on to something they are already taking) it will be a good idea to look at the side effects of the different antidepressants together.

Some are going to cause sleepiness (which might be a good thing if your child is not sleeping), some will cause them to feel more awake (which may be a good thing if they have a hard time getting going in the mornings), some will cause weight gain (which may be a good thing if they are losing weight too much), some don't play well with other medications they are taking (which is a good thing if they are taking any other medications regularly) etc. 

Certain antidepressants should be used with caution in those with seizures, cardiac issues, or Bipolar Disorder, so be sure to remind your child’s healthcare provider of any family history or personal history of either or the above.

Work with your child’s healthcare provider to make sure that the second antidepressant chosen fits your child’s needs, health history and preferences.

I have provided a Quick Guide here outlining the options when trying out a second antidepressant. It also covers things to remember and questions to ask at your child's next appointment with their healthcare provider if your child is trying out a second antidepressant.

This site is for general informational purposes only and does not constitute the giving of medical advice. The contents do not constitute the practice of medicine, nursing, or other professional health care services. No provider–patient relationship is formed.