Switching or Augmentation Strategies in the Treatment of Major Depressive Disorder – What Does the Evidence Tell Us?
When patients with Major Depressive Disorder (MDD) don’t respond to medication, clinicians have three options: Increase dose, switch or augment.
Switching seems to be the favoured strategy, with 85% of psychopharmacologists endorsing switching and 11% endorsing augmentation in one study. [Goldberg et al ., 2015]
However, there is no clear consensus about the most optimal strategy.
In this article, we examine the evidence for switching vs augmentation strategies in managing major depressive disorder after an initial non-response to AD.
Bauer, M., Pfennig, A., Severus, E., Whybrow, P. C., Angst, J., Moeller, H. J., & Šon behalf of the Task Force on Unipolar Depressive Disorders. (2013). World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders. The world journal of biological psychiatry, 14(5), 334-385.
Mohamed, S., Johnson, G. R., Chen, P., Hicks, P. B., Davis, L. L., Yoon, J., … & VAST-D Investigators. (2017). Effect of antidepressant switching vs augmentation on remission among patients with major depressive disorder unresponsive to antidepressant treatment: the VAST-D randomized clinical trial. Jama, 318(2), 132-145.
MacQueen, G., Santaguida, P., Keshavarz, H., Jaworska, N., Levine, M., Beyene, J., & Raina, P. (2017). Systematic review of clinical practice guidelines for failed antidepressant treatment response in major depressive disorder, dysthymia, and subthreshold depression in adults. The Canadian Journal of Psychiatry, 62(1), 11-23.
Kennedy SH, Lam RW, McIntyre RS, Tourjman SV, Bhat V, Blier P, Hasnain M, Jollant F, Levitt AJ, MacQueen GM, McInerney SJ, McIntosh D, Milev RV, Müller DJ, Parikh SV, Pearson NL, Ravindran AV, Uher R; CANMAT Depression Work Group. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments. Can J Psychiatry. 2016 Sep;61(9):540-60.
Kato, T., Furukawa, T. A., Mantani, A., Kurata, K. I., Kubouchi, H., Hirota, S., … & Guyatt, G. H. (2018). Optimising first-and second-line treatment strategies for untreated major depressive disorder—the SUN☺ D study: a pragmatic, multi-centre, assessor-blinded randomised controlled trial. BMC medicine, 16(1), 1-16.
Köhler-Forsberg, O., Larsen, E. R., Buttenschøn, H. N., Rietschel, M., Hauser, J., Souery, D., … & Mors, O. (2019). Effect of antidepressant switching between nortriptyline and escitalopram after a failed first antidepressant treatment among patients with major depressive disorder. The British Journal of Psychiatry, 215(2), 494-501.
Montgomery, S. A., Nielsen, R. Z., Poulsen, L. H., & Häggström, L. (2014). A randomised, double‐blind study in adults with major depressive disorder with an inadequate response to a single course of selective serotonin reuptake inhibitor or serotonin–noradrenaline reuptake inhibitor treatment switched to vortioxetine or agomelatine. Human Psychopharmacology: Clinical and Experimental, 29(5), 470-482.
Scott, F., Hampsey, E., Gnanaprgasam, S., Carter, B., Marwood, L., Taylor, R., … & Strawbridge, B. (2022). Systematic review and meta-analysis of augmentation and combination treatments for early-stage treatment-resistant depression: Adjunctive therapies for non-responsive depression. Journal of Psychopharmacology.