title: Strategies for managing depression refractory to selective serotonin reuptake inhibitor treatment: a survey of clinicians.
abstract: OBJECTIVE
  To examine treatment practices in cases where selective serotonin reuptake inhibitors (SSRIs) are ineffective.
  
  
  METHODS
  We surveyed 801 clinicians (including 630 psychiatrists) attending the Massachusetts General Hospital's annual psychopharmacology review course. Clinicians were presented with a vignette about a patient with depression who had responded partially to an SSRI and were asked to choose among various strategies available to manage this patient.
  
  
  RESULTS
  Of those surveyed, 466 clinicians had been in practice a mean of 16.6 years (SD 10.7). Not all clinicians chose to answer every question. Among 455 respondents, 84% (n = 382) chose to increase the dose of the SSRI, 10% (n = 47) chose augmentation or combination, and 7% (n = 31) opted for switching agents. When asked to switch to another agent, 448 responded, of whom 52% (n = 235) chose a newer antidepressant, 34% (n = 152) chose another SSRI, 10% (n = 44) chose a tricyclic antidepressant (TCA), 2% (n = 8) chose a serotonin norepinephrine reuptake inhibitor (SNRI), 1% (n = 5) chose a monoamine oxidase inhibitor (MAOI), and 1% (n = 4) chose an undefined "other" agent. Among 445 respondents, bupropion was the most widely chosen augmenting agent (30%, n = 134), followed by lithium (22%, n = 98). West coast and Canadian clinicians preferred to switch to another SSRI rather than to a newer antidepressant. Canadian clinicians preferred lithium to bupropion as their first-choice augmenting agent, as did clinicians from academic settings. Clinicians from community, individual practice, or group settings favoured bupropion. More experienced clinicians preferred bupropion as a first-choice augmenter, whereas less experienced ones showed a slight preference for lithium. Canadian clinicians were more likely to use MAOIs as second-line agents.
  
  
  CONCLUSIONS
  Clinicians in this sample often followed strategies different from those recommended in the literature. Bupropion may have an important role in augmentating treatment with SSRIs.
authors.affiliation: Depression Clinical and Research Program, Massachusetts General Hospital, Boston 02114, USA. dmischoulon@partners.org
authors.forename: D
authors.initials: D
authors.lastname: Mischoulon
authors.forename: A A
authors.initials: AA
authors.lastname: Nierenberg
authors.forename: L
authors.initials: L
authors.lastname: Kizilbash
authors.forename: J F
authors.initials: JF
authors.lastname: Rosenbaum
authors.forename: M
authors.initials: M
authors.lastname: Fava
mesh_terms: D018692:Antimanic Agents / Q000627:therapeutic use; D016642:Bupropion / Q000627:therapeutic use*; D003866:Depressive Disorder / Q000188:drug therapy*; D005260:Female; D006801:Humans; D008094:Lithium / Q000627:therapeutic use; D008297:Male; D011361:Professional Competence; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use*; D011795:Surveys and Questionnaires
chemical_list: D018692:Antimanic Agents; D016642:Bupropion; D008094:Lithium; D017367:Selective Serotonin Reuptake Inhibitors