Treatment choice after one antidepressant fails: a survey of northeastern psychiatrists.
BACKGROUND
Because limited evidence exists to help clinicians choose the next step after a depressed patient fails to respond to an adequate trial of an antidepressant, I conducted a survey to explore psychiatrists' treatment choices.


METHODS
I asked 118 northeastern psychiatrists what they would do next in response to a clinical vignette of an inpatient with DMS-III-R major depression who failed to respond to 4 weeks of nortriptyline at adequate blood levels.


RESULTS
Lithium augmentation was chosen by more than a third (33.9%) of psychiatrists. Other choices, in order of decreasing frequency, were continuing nortriptyline for another 2 weeks (17.8%) and switching to either fluoxetine (16.1%), electroconvulsive therapy (11.0%), or a monoamine oxidase inhibitor (6.8%). Only one psychiatrist each chose thyroid augmentation or bupropion.


CONCLUSIONS
The surveyed psychiatrists overwhelmingly preferred lithium augmentation over other strategies to manage treatment-resistant depression. Research on comparative strategies is lacking and urgently needed.
Nierenberg
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Treatment Resistant Depression Program, McLean Hospital, Belmont, MA 02178.
D000928:Antidepressive Agents / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D016642:Bupropion; D003657:Decision Making; D003866:Depressive Disorder / Q000188:drug therapy / Q000523:psychology / Q000628:therapy*; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D004565:Electroconvulsive Therapy; D005473:Fluoxetine / Q000627:therapeutic use; D006801:Humans; D008094:Lithium / Q000627:therapeutic use; D009661:Nortriptyline / Q000627:therapeutic use; D011427:Propiophenones / Q000627:therapeutic use; D011570:Psychiatry; D014284:Triiodothyronine / Q000627:therapeutic use
D000928:Antidepressive Agents; D011427:Propiophenones; D005473:Fluoxetine; D016642:Bupropion; D014284:Triiodothyronine; D008094:Lithium; D009661:Nortriptyline