Clinical inquiries: How should you manage a depressed patient unresponsive to an SSRI?
The best approach among studied alternatives to manage a patient with treatment-resistant depression is not clear from the evidence. All of the options reviewed seem to have about a 25% to 30% success rate. Switching to other antidepressants or augmenting with non-antidepressant drugs has the best supporting evidence (strength of recommendation [SOR]: B).1 Adding additional antidepressants (SOR: B), using psychotherapy (SOR: B), and initiating electroconvulsive therapy (ECT) (SOR: C) are options. Various antidepressants are used as add-on therapy. Psychotherapy is often recommended, though the evidence of benefit after a failed course of initial therapy is sparse. The evidence supporting use of ECT in treatment-resistant depression is weak. Comparison among the options is based on expert opinion (SOR: C). Additional reports from the STAR*D trial may improve the quality of the evidence in the near future.
Triezenberg
Daniel
D
Family Practice Residency, Saint Joseph Regional Medical Center, South Bend, IN, USA.
Vachon
Dominic
D
Helmen
Jennifer
J
Schneider
David
D
D000928:Antidepressive Agents / Q000627:therapeutic use*; D018687:Antidepressive Agents, Second-Generation / Q000627:therapeutic use; D003131:Combined Modality Therapy; D003863:Depression / Q000188:drug therapy / Q000628:therapy*; D004565:Electroconvulsive Therapy / Q000379:methods*; D019317:Evidence-Based Medicine; D006801:Humans; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care / Q000592:standards; D011613:Psychotherapy / Q000379:methods*; D012107:Research Design; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use
D000928:Antidepressive Agents; D018687:Antidepressive Agents, Second-Generation; D017367:Selective Serotonin Reuptake Inhibitors