Flexible treatment strategies in chronic disease: Clinical and research implications

Multiple treatments are available for nearly all the mood disorders. This r ange of treatment options adds a new dimension of choice to clinical decisi on making. In addition to prescribing the best initial treatment, clinician s should have an algorithm for deciding if and when to make subsequent chan ges in treatment to take advantage of second-line treatment options when ne cessary. This article aims to 1) show that a wide variety of clinical decis ions can be framed as choices among adaptive (within-patient) threshold-bas ed strategies or algorithms, illustrating the generality of the concept; 2) illustrate two ways to design randomized clinical trials to compare treatm ent strategies with each other to decide which strategy is best; and 3) dis cuss some of the advantages offered by these designs, in terms of both pati ent acceptability and adherence to experimental protocols. (C) 2000 Society of Biological Psychiatry.