Stage Three and Beyond, Depression Treatment According to TMAP

This post discusses stage three 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.

In earlier posts, I talked about Stage 1 and Stage 2 depression treatment using TMAP.
Basically, each step consists of giving a medicine (or medicines for Stage 1A and Stage 2A) and gradually increasing the dose. While we increase the dose. we monitor the patient for improvement with the PHQ-9 depression symptom measurement (or the QIDS-SR16 used in TMAP—either is fine and there are also others that could also be used). While increasing the dose we also monitor for side effects with a side-effects questionnaire.

If the patient’s depression symptoms go away, the patient stays on the medicine or medicines of that stage usually for at least six to nine months or longer. If the medicine(s) do not completely relieve the symptoms or if the person has unacceptable side-effects, we stop the medicine(s) and proceed to the next step in the algorithm (plan). We proceed to Stage 3.

Stage 3

In Stage 3 we can use combination medicines different from the ones used in Stage 1 or Stage 2.

There are five classes of antidepressant medicines: the selective serotinin reuptake inhibitors (SSRIs), the serotinin norepinephrine reuptake inhibitors (SNRIs), the tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and finally the others class.

In stage 3 we might use an SSRI or SNRI that had not been previously used along with an augmenting agent (bupropion, mertazapine,or an atypical antipsychotic [for example, the heavily advertised Abilify—aripiprazole]).

Alternatively, you and the doctor might choose to use a tricyclic antidepressant alone, or less likely, a monoamine oxidase inhibitor alone.

And just as you did in stages one and two, you and your doctor gradually increase the dose of the medicine(s) and check for improvement (hopefully, resolution) of your symptoms and check for side effects.

Beyond Stage 3

If your symptoms do not resolve with the stage 3 treatment the document includes recommendations for additional steps. These steps are complicated and your doctor, whether a psychiatrist or primary care physician, might recommend a second opinion consultation before proceeding.

But again, don’t give up. Even complex and long standing severe depression can be very successfully treated but you and your doctors will have to keep plugging away.

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