Strategies for managing depression refractory to selective serotonin reuptake inhibitor treatment: A survey of clinicians

Objective: To examine treatment practices in cases where selective serotoni n reuptake inhibitors (SSRIs) are ineffective. Methods: We surveyed 801 clinicians (including 630 psychiatrists) attending the Massachusetts General Hospital's annual psychopharmacology review cour se. Clinicians were presented with a vignette about a patient with depressi on who had, responded partially to an SSRI and were asked to choose among v arious strategies available to manage this patient. Results: Of those surveyed, 466 clinicians had been in practice a mean of 1 6.6 years (SD 10.7). Not all clinicians chose to answer every question. Amo ng 455 respondents, 84% (n = 382) chose to increase the dose of the SSRI, 1 0% (n = 47) chose augmentation or combination, and 7% (n = 31) opted for sw itching agents. When asked to switch to another agent, 448 responded of who m 52% (n = 235) chose a newer antidepressant, 34% (n = 152) chose another S SRI, 10% (n = 44) chose a tricyclic antidepressant (TCA), 2% (n = 8) chose a serotonin norepinephrine reuptake inhibitor (SNRI), 1% (n = 5) chose a mo noamine oxidase inhibitor (MAOI), and 1% (n = 4) chose an undefined "other " agent. Among 445 respondents, bupropion was the most widely chosen augmen ting 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 n ewer antidepressant. Canadian clinicians preferred lithium to bupropion as their first-choice augmenting agent, as did clinicians from academic settin gs. Clinicians from community, individual practice, or group settings favou red bupropion. More experienced clinicians preferred bupropion as a first-c hoice augmenter, whereas less experienced ones showed a slight preference f or lithium. Canadian clinicians were more likely to use MAOIs as second-lin e agents. Conclusions: Clinicians in this sample often followed strategies different from those recommended in the literature. Bupropion may have an important r ole in augmentating treatment with SSRIs.