Partial response, nonresponse, and relapse with selective serotonin reuptake inhibitors in major depression: A survey of current "next-step" practices

Background: Many patients treated for major depression require more than on e antidepressant trial to achieve or sustain response However, the literatu re provides few treatment algorithms or effectiveness studies that empirica lly support "next-step" options available to clinicians. We conducted a sun ey of psychiatrists and other medical specialists who treat depression to ascertain what clinicians actually do when faced with patients who suboptim ally respond to an adequate course of selective serotonin reuptake inhibito r (SSRI) therapy. Method: Attendees at a psychopharmacology course (N = 801) were queried abo ut their top choices for antidepressant-treatment nonresponders: a minimal responder after 4 weeks of adequate SSRI treatment, a partial responder aft er 8 weeks of adequate SSRI therapy, a nonresponder after 8 weeks of adequa te SSRI therapy, and a relapser on long-term SSRI maintenance therapy, Choi ces included raising the dose, augmenting or combining with another agent, switching to a second SSRI, or switching to a non-SSRI agent. Results: 432 (54%) of the surveys were returned. Raising the dose was the m ost frequently reported next-step strategy for a patient with minimal respo nse after if weeks of adequate SSRI therapy, partial response after 8 weeks of adequate SSRI therapy, and relapse on long-term SSRI therapy. Switching to a non-SSRI agent was the most frequently chosen option for nonresponder s to an adequate trial of SSRI therapy. Conclusion: Our findings suggest that clinicians select different next-step strategies when patients are nonresponders versus when patients are partia l responders or relapsers.