Depression

Depression medication, diagnosed before it is dosed.

The most common story in this practice is not a first depression. It is the second or third medication, the one that worked for a while or never quite worked, prescribed a little higher each visit by someone with six minutes to spare. Depression medication management here starts with a different question: not “what should we try next,” but “why did the last one fail?” Dose, thyroid, B12, vitamin D, iron, sleep: the answer is in the workup more often than it is in a newer drug.

The failure checklist

Six reasons an antidepressant "doesn't work"

Before any switch or augmentation is discussed, your history gets audited against the usual suspects. Most failed trials fail for a findable reason, and the reason dictates the fix.

The moves, in order

Optimize, switch, augment, test

When the checklist is cleared and a medication still is not earning its place, the sequence is deliberate. First, optimize: the current drug at a real dose for a real duration, because it is the fastest honest answer. Second, switch: a different class with a different mechanism, chosen against your history and your side-effect ledger, not the formulary's mood. Third, augment: adding a targeted second agent to a partial response instead of discarding work that half succeeded. And woven through all three, testing when guessing has cost enough: GeneSight can show whether your body was ever giving the failed drugs a fair chance, and the functional workup covers the physical half of the same question. The full diagnostic reasoning, step by step, is written out in the guide to an antidepressant that stopped working.

One more thing this page should say out loud, because patients hear the opposite so often: needing a second or third approach is not a verdict on you. Depression treatment is iterative for almost everyone. What distinguishes good care is not a lucky first guess; it is a prescriber who treats each result as information and keeps the search organized.

Adjustment and, eventually, subtraction

Remission is a beginning, not a life sentence

Side effects get weighed at every follow-up with the same seriousness as symptoms: the emotional blunting, the sexual side effects people apologize for mentioning, the weight that creeps. A medication you dread taking is a medication you will quietly stop, so we adjust early and honestly. And when remission has held, through seasons and not just weeks, the deprescribing conversation opens: whether to continue, and for how long, is a decision we revisit with your history in view, and any taper is slow enough that your brain is never asked to notice it. Coming off an antidepressant badly is how people conclude they can never come off one. Done properly, it is unremarkable, which is exactly the point.

The plateau

Partial credit is still a decision point

The commonest outcome of a first antidepressant is neither failure nor remission. It is partial: the volume turns down, the worst days soften, and then the line flattens somewhere short of well. Partial response is information with its own protocol. First, the honest audit: doses actually taken, alcohol actually counted, sleep actually slept, because a plateau built on half a regimen is a mirage. Then the judgment call, made with you and not for you: push the current medication further, augment it with a second agent aimed at what remains, or switch and spend the partial gains as the price of a better fit. There is no house rule that always wins. There is a prescriber who tracks which lever has not been pulled yet, and a score that says whether the last pull worked.

If this is not your first episode, the planning horizon lengthens. Recurrence is a property of the illness, not a failure of the patient, and a history of returning depressions argues for staying on a working medication longer, tapering later and slower, and knowing your personal relapse signature: the specific early signs, yours and not a textbook's, that say the slide has started. Those signs get written into your plan while you are well, along with the agreement that you call when they appear rather than waiting for the next scheduled visit. Caught at the signature stage, a recurrence is often a dose adjustment. Caught three months in, it is another episode. The difference is mostly timing, and timing is something a practice can actually organize.

Sleep keeps score alongside mood here: the ISI rides with the PHQ-9 at intake and at follow-ups, because a depression score that will not fall while sleep stays broken is usually telling one story, not two. You will see both lines. Patients who watch their own scores tend to change what happens between visits in ways no advice from me can match.