Patients’ perspectives of taking two antidepressants for treatment-resistant depression (TRD): A qualitative study

Katie Dixon, David Kessler, Alison Lloyd, Heather Burroughs, Debbie Tallon, Carolyn Chew-Graham

Research output: Contribution to conferenceConference Paperpeer-review


The problem:
Depression is a leading cause of disease burden and most patients with depression are managed in primary care. A number of definitions of treatment resistant depression (TRD) have been proposed, and it is estimated that 50% of patients still meet criteria for depression despite taking an adequate dose of antidepressants for at least 4 consecutive weeks. The NICE guideline
for depression suggests that GPs should re-consider treatment options if there has been no response after 4 to 6 weeks of antidepressant medication: one option is to combine antidepressants.

There is limited literature reporting patients’ views on the acceptability of antidepressants, but no evidence about combination pharmacological therapy for depression. The aim of this study was to explore perspectives of patients with TRD, who declined to participate in a trial of the addition of mirtazapine or placebo to those who had not responded to at least 6 weeks of a selective serotonin reuptake inhibitor or a serotonin or norepinephrine reuptake inhibitor

The approach:
This study is nested in a randomised, placebo-controlled trial of mirtazapine in addition to SSRI/SNRI antidepressants for TRD. Primary care patients, prescribed SSRIs or SNRIs, were invited by letter to participate in the trial. The invitation letter included a short questionnaire for completion by those who did not wish to take part. The questionnaire gave closed options for people to express reasons for declining to participate, plus a box for free text. In-depth telephone interviews were conducted with a sub-group of those who returned this ‘decliner’ questionnaire and expressed a willingness to be interviewed about their reasons for declining. Interviews were digitally recorded with consent and transcribed. The data were analysed using a constant comparison approach.

The study is ongoing. Predominant reasons given for declining are not wanting to be part of a research study and only wanting to take one antidepressant. Ten interviews have so far been conducted. Initial analysis suggests that patients understand depression as a complex problem, so complex strategies for management are needed. One antidepressant is seen to be a logical
response to the ‘depression as a chemical imbalance’ story, and core to recovery, by some patients. The use of two antidepressants, however, was not seen as logical, and was described as disturbing what is perceived as a ‘fragile equilibrium’. A fear of additional side effects of combining two antidepressants was also expressed.

The NICE guideline for depression, suggesting a combination of antidepressants be considered by GPs for patients with treatment resistant depression, needs to be cognisant of patients’ perspectives concerning this strategy, and recognise when there is a reluctance to disturb the current, acceptable, treatment regime.
Original languageEnglish
Publication statusPublished - 10 Jul 2014
EventSociety for Academic Primary Care: Annual Scientific Meeting - Edinburgh, United Kingdom
Duration: 10 Jul 2014 → …
Conference number: 43


ConferenceSociety for Academic Primary Care
Abbreviated titleSAPC ASM
Country/TerritoryUnited Kingdom
Period10/07/14 → …


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