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Higher doses are necessary for treatment of obsessive compulsive disorder.Nortriptyline is less sedating, and less likely to cause hypotension or anticholinergic effects than amitriptyline, dothiepin, doxepin and trimipramine.Continuation of the same antidepressant can also be considered in patients who show a partial response at 6 weeks.Treatment resistance This is defined as a lack of satisfactory response after a trial of two antidepressants given sequentially at an adequate dose for an adequate time, with or without psychological therapy.Dose titration for both SSRIs and TCAs is usually slower for anxious patients as they appear more sensitive to side effects.It is not unusual for anxious patients to have more anxiety during the titration of SSRIs.When withdrawing treatment on completion or otherwise, reduce the dose gradually over at least 4 weeks to avoid discontinuation symptoms.Some improvement is usually seen within two weeks of starting antidepressant treatment at a therapeutic dose.
MAOIs (phenelzine, tranylcypromine) are now rarely used because of their severe, and potentially fatal, interactions with some foods and medications.
They should only be initiated by psychiatrists familiar with their use.
Moclobemide may be useful, particularly in patients who are intolerant of the adverse effects of other antidepressants.
An adult with depression who is responding to antidepressant treatment should normally continue to take the antidepressant for at least 6 months after remission (not just after the initial response) of an episode of depression in order to reduce the risk of relapse.
Patients who have had two or more depressive episodes in the recent past, and who have experienced significant functional impairment during the episodes, should be advised to continue antidepressants for 2 years.
A different medication often works even if the first option has been unsuccessful.