Augmenting antidepressants

Question 1

Algorithm for treatment resistant depression (TRD)

Answer 1

Lack of response to current antidepressant

CONSIDER
-Pseudo TRD
—-thyroid, nonadherance, latent bipolar

TRUE TRD
-No improvement at all or intolerable AE
—-switch to another in the same class
-Partial and unsatisying improvement
—-augmentation strategies like other antidepressant, lithium, atypical or combo with psychotherapy
-nonresponse to 2 or 3 adequate antidepressant trials
—-neurostimulation, antidepressants with innovative MOA

Question 2

adjunctive medication options

Answer 2

atpyicals
antidepressants
lithium
T3
stimulants

Question 3

atypicals with meta analysis and with RCT

Answer 3

meta analyses
-aripiprazole
-olanzapine
—–+fluoxetine: mixed results vs monotherapy
-quetiapine
-risperidone

RCT
-Brexpiprazole
-ziprasidone

overall worse tolerability than placebo

Question 4

antidepressant adjuncts

Answer 4

-poss efficacy for mirtazapine

• no difference for combos
  ► Bupropion + escitalopram vs. either alone
  ► Escitalopram + bupropion SR vs. escitalopram
  ► Mirtazapine + venlafaxine vs. escitalopram

adjunctive use of antidepressants is assoc with inc AE compared to monotherapy

Question 5

Lithium as adjunct

Answer 5

effective though small trials

Lithium +TCA

Lithium + SSRI
- 3 trials and 74 patients

Question 6

Triiodothyronine (T3)

Answer 6

2 RCT
better tolerated than lithium

Question 7

stimulants as adjunct

Answer 7

modafanil
- marginal evidence/mixed results

Lisdexamfetamine
- partial response
-other trials neg
- other stimulant trials neg

Question 8

Tx for depression after unsatisfactory response to SSRI according to AHRQ

Answer 8

Insufficient evidence to eval benefits of
-dose change
-SSRI switch
-Non SSRI antidep switch
-Non andidepressant switch
-Nonpharm tx switch
-Ongoing monotherapy with SSRI as opposed to adjunctive antidepressant

Comparable result when switch to another antidep or adding non antidep to the initial SSRI

Adding atypical antipsych to SSRI is assoc with higher response and remission rates vs placebo

Insuff evidence for other augmentation strategies

Question 9

strongest evidence for adjunctive rx
better than placebo

Answer 9

aripiprazole
quetiapine

better than placebo
- Lithium
-T3