Kindly explain about the best medication for major depression from SNRI group?

Question

Hello doctor,

I need help for my 19-year-old son. He has tried SSRI's which did not work (Then we had the Gene testing done and it showed that he should not be on the one that he was on) and seemed to make him worse. He is now on an SNRI, the same one that his mother is on and that is not working as it should either. We have tried the Ketamine treatments and they seem to help short term (a couple of days). We stop those treatments when he was hospitalized at the end of last year. He was required to be hospitalized to be observed for ECT treatments which were started. We saw a great improvement with the ECT and after about 7 treatments, he was backed off to once a week which seemed to work okay, with only one bad day. Then he was moved to every two weeks and it got bad again. We got him in a few days before the two weeks were up and he still had some very bad days. He is a psychiatrist but my son is not honest with him because he fears being locked up again.

I guess my question is this. What medication in the SNRI class have you found to work the best for major depression? (I know he has been labeled treatment-resistant but the anxiety medication he takes seems to work). Is there another class of medication that you would suggest we try?

Answer 1

Hello,

Welcome to icliniq.com.

Firstly sir, it is just a brief labelling to broadly differentiate classes, but many people who do not respond to one SSRI/SNRI, will do well with another drug of the same class, so cross switching between classes is also done.

Among the SNRI, my personal experience as well as the literature, supports the use of Venlafaxine as superior compared to others. Lets assume that we are going to use Venlafaxine as a primary drug. In non responders or resistant, usually augmenting agents are given. I do not know what agents have been tried for your son so far. But normally, SNRI with mood stabilizer like Sodium valproate or Lithium, or SNRI+low dose second generation antipsychotic, or SNRI plus combinations of mood stabilizer and low dose antipsychotics can be used. Apart from this other classes of drugs can also help such as Mirtazepine, Bupropion, and as and when needed temporary use of low dose Benzodiazipines and Propranolol can also be added.

The goal here will be remission of symptoms or atleast reduction to an acceptable level. In patients with resistance, usually 2 or 3 drug combinations will be needed. Also many psychiatrists do not reach the maximal dosage recommended of most drugs and that also needs to be tried out. Apart from this, you should consider getting 6 to 8 sessions of cognitive behavioural therapy from a clinical psychologist. It will also help and add to the effect of medicines.