Depression Clinical Pathway — Outpatient Behavioral Health and Primary Care
Depression Clinical Pathway — Outpatient Behavioral Health and Primary Care
Treatment of Non-Responders or Resistant Depression
If no clinical response to first or second line medications, pediatricians should refer to or consult with psychiatry for review of patient treatment plan before proceeding.
- Treatment Resistant Depression is depression that does not respond to an adequate trial (based on dose and duration) of an evidence-based treatment.
- As an example, an adequate trial of an SSRI should be at least eight weeks in duration, with the last 4 weeks at a dosage equivalent to Fluoxetine 40mg or Escitalopram 20 mg.
- For children and adolescents who have shown a poor response to an adequate dose and duration of an antidepressant, providers should assess adherence to medication, presence of psychiatric or medical co-morbidity, quality of sleep, and contributing psychosocial factors.
- Predictors of poorer treatment response to antidepressant medication includes severity, chronicity, co-morbidity, substance use, family discord, history of abuse, current parental depression, and hopelessness.
- Medical history and selected laboratory tests may be clinically indicated for a patient with chronically unresponsive depression.
- Possible screening laboratory tests might include CBC, TSH, B12 and Folate, Urine toxicology, Vitamin D, CRP, or trough drug levels/metabolites.
- Specific chronic illnesses that have been shown to have increased rates of depression include epilepsy, asthma and atopic illnesses, inflammatory disorders, diabetes, and migraine.
- Medications such as steroids, anti-epileptics, interferon, and oral contraceptives might increase the risk for depression as well.
- A switch to a second SSRI and/or the addition of psychotherapy or other psychosocial interventions is recommended for the child or adolescent who has shown an incomplete response to a medication that has been optimized.
- Primary care clinicians should consider referral or consultation with a child and adolescent psychiatrist.
- There is no data in adolescents to guide the clinician in the management of a patient who presents with a history of non-response to two SSRIs. Alternative antidepressants therapies that are not approved by the FDA for children and adolescents but may have benefit include (in no particular order):
- Switch to another SSRI including Sertraline or Citalopram (non-formulary)
- Switch to an SNRI including Duloxetine or Venlafaxine (non-formulary)
- Switch to Bupropion
- Switch to Mirtazapine
- There are no studies in children and adolescents regarding augmentation strategies. Adult studies support augmenting antidepressants with additional pharmacological agents for treatment resistant depression. Augmentation strategies might include (in no particular order):
- Addition of Mirtazapine (helpful for residual sleep difficulties)
- Addition of Bupropion (helpful for daytime fatigue, low energy, or impaired concentration)
- Addition of Buspirone (helpful for co-occurring anxiety disorders)
- Addition of Atypical Antipsychotics (helpful for residual irritability or mood lability)
- Additional medications that might be considered if the above-noted strategies either do not work or cannot be tolerated may include Tri-Cyclic Antidepressants, Lamotrigine, and Monoamine Oxidase Inhibitors.
- Non-pharmacological interventions for treatment resistant depression should also be considered and would include Electroconvulsive Therapy (ECT), Vagus Nerve Stimulation, Transmagnetic Stimulation, and Deep Brain Stimulation.
- For additional information on medications, please refer to formulary .