When Switching Meds Isn’t the Best Approach

Many patients with depression do not get relief from the first drug they are treated with. A new study indicates that augmenting an antidepressant with an antipsychotic may yield a greater benefit than switching the patient to another antidepressant.

Investigators had initially questioned if there was a difference among pharmacotherapeutic approaches for treating patients with depression who were not responding to an antidepressant treatment. “We found that among three strategies evaluated in this study, evidence of the greatest symptom benefit was provided by adding an antipsychotic to previous antidepressant therapy,” lead author Somaia Mohamed, MD, PhD, said in a statement. She is associate clinical professor of psychiatry at Yale University School of Medicine and the VA Connecticut Healthcare System in West Haven.

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The research involved 1,522 patients, at 35 U.S. Veterans Health Administration medical centers, of whom 85% were male. Investigators found that these patients benefitted more when an antipsychotic treatment was added to their regimen than if they switched to another antidepressant. The study appeared July 11 in JAMA.

Patients participated in the study from December 2012 to May 2015. They had been diagnosed with nonpsychotic major depressive disorder, and were not responding to at least one antidepressant course meeting minimal standards for treatment dose and duration. The patients were randomly assigned to one of three treatments and evaluated for up to 36 weeks. Mohamed told Drug Topics that 12 weeks is the usual study time, but that 36 weeks was needed to better determine efficacy, safety, and various other effects of antipsychotics.

The study showed that that about 29% of patients who took the antipsychotic aripiprazole (Abilify) for 12 weeks, along with their original antidepressant, experienced almost complete remission of their depression symptoms. The remission rates at 12 weeks totaled 22.3% for the group that switched to another antidepressant, bupropion; 26.9% for the group whose treatment was augmented with bupropion; and 28.9% for the group whose treatment was augmented with aripiprazole.

Those taking aripiprazole were significantly more likely to show a clinically meaningful response to their treatment than either switching to another antidepressant or adding another antidepressant to the original medication, Mohamed and colleagues reported.

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The researchers noted that among a predominantly male population who were unresponsive to antidepressant treatment, augmentation with aripiprazole resulted in a statistically significant but modestly increased likelihood of remission during 12 weeks of treatment. Given this and the potential adverse effects associated with aripiprazole, they believe that additional analyses, including an evaluation of cost-effectiveness, are needed to understand the net utility of this treatment.

Less than 33% of 16 million Americans who experience major depression obtain relief of symptoms from the first drug prescribed, according to the statement.