instruction: hello doctor I need help for my 19 year old son he has tried sari 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 sari 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 eat treatments which were started we saw a great improvement with the eat and after about 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 sari 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
output: hello firstly sir it is just a brief labelling to broadly differentiate classes but many people who do not respond to one sari will do well with another drug of the same class so cross switching between classes is also done among the sari 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 sari with mood stabilizer like sodium valproate or lithium or sari low dose second generation antipsychotic or sari 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 or 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 to sessions of cognitive behavioural therapy from a clinical psychologist it will also help and add to the effect of medicines