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Augmentation Strategies in Treatment-Resistant Depression

(PSYCHIATRIC TIMES) - The treatment of unipolar major depression presents a substantial challenge for the clinician. Major depression is a common disorder1 with a high propensity for relapse and recurrence.2 In addition, it is increasingly evident that antidepressant treatment offers moderate benefits and that sequential treatments are invariably required to obtain a satisfactory therapeutic effect.

Recent research findings confirm earlier observations that about 50% of patients with major depression respond to an adequate antidepressant trial, and far fewer, about one third, will achieve full remission.3,4 Moreover, if a patient fails to respond to 2 sequential antidepressant trials, remission rates are alarmingly low, approximately 10% to 15% with yet a third antidepressant.5 Remission is the goal of antidepressant therapy, yet it is estimated that first antidepressant trials (usually with an SSRI) fail in more than one half to two thirds of patients, requiring further therapeutic intervention. There are several options available for such patients;

While there is limited clinical trial evidence for the efficacy of these options, few have undergone rigorous randomized, controlled trials. Furthermore, there are few data on the comparable efficacy of these various options. For example, a recent report from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial showed no significant difference in remission rates when either bupropion or buspirone was given to patients who failed to respond to or could not tolerate a trial of the SSRI citalopram.6

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