Stage Two Depression Treatment According to TMAP

In an earlier post, I discussed stage 1 and stage 1A treatment recommendations of the TMAP depression manual.

This post discusses stage two of the treatment stages for depression using the Texas Medication Algorithm Project Guidelines for Depression. See Texas Medication Algorithm Project Procedural Manual: Major Depressive Disorder Algorithm.

Stage 2
If the medicine in stage 1 or the medicines in stage 1A did not help your depression or caused unacceptable side effects, then it is time to move to the next stage, stage 2.

There are five different classes of antidepressants. In Stage 1, the recommendation (usually) is for the antidepressant to be a member of the selective serotonin reuptake inhibitors (SSRIs) or the serotonin norepinephrine reuptake inhibitors (SNRIs)

If you were taking an SSRI in stage one, then the recommendation is to discontinue that and begin an SNRI. If you were taking an SNRI, then switch to an SSRI. You will gradually increase the dose monitoring for improvement or side-effects just as you did with your step one medicine.

Although overall, the different medicines in each class, and the different classes of antidepressants are all equally effective, each person is very different. And so for an individual patient, one antidepressant or one class of antidepressant may work much better than another. So if one medicine in a given class doesn’t work, another medicine in the same class or from a different class may work very well.

That’s why it is so important to not give up. If one medicine doesn’t work, it is likely that a different one or different combination will. In stage 2, you and the doctor will gradually increase the dose of your medicine watching for improvement or side effects, just as you did for your stage 1 medicine.

If your stage 2 medicine helps your depression but doesn’t take away all your depression symptoms then we go to stage 2A.

Stage 2A
If the medicine in stage 2 helps your depression but doesn’t get rid of the symptoms, then we augment (add) another medicine to your stage 2 antidepressant. It is the same strategy as used in Step 1A.

In this stage your medicine has helped your depression, but you’re symptoms aren’t gone. You aren’t back to where you were (and remember, the goal of modern depression treatment is remission of symptoms not just better).

You’re on the recommended maximum dose (for you) and you’ve been taking it for a long enough time.

So in this step, you stay on the medicine that is helping, but you and your doctor add another medicine with a different mechanism of action. If you are currently taking an SSRI or SNRI, the recommendation is to add bupropion, mirtazapine, lithium, liothyronine (T3, a specific thyroid hormone), or buspirone.

If you are taking bupropion or mirtazpine, then you augment (add) an SSRI or SNRI.

If you went through Step 1A before going to Step 2, your doctor will use likely use medicines that weren’t tried in Step 1 or Step 1 A.

And you and your doctor gradually increase the dose of the second agent, watching for side effects and for improvement.

If your symptoms of depression remit, then you will continue on the medicine of Step 2 or the medicines of Step 2A.

If you haven’t gotten better, then you and the doctor should proceed to Step 3. Again, the key is not to give up.

In the next post, I’ll talk about Step 3 and beyond.

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