A systematic review of augmentation strategies for patients with major depressive disorder.

Center for Health Economics and Science Policy, United BioSource Corporation, Bethesda, MD.

“Major depressive disorder (MDD) is a leading cause of disability worldwide. Clinicians need to determine the most appropriate and effective interventions for patients who do not benefit from first-line treatment. A systematic review of the literature on augmentation strategies for major depression was conducted. A total of 32 eligible studies were included in the final review. Identified augmentation strategies included lithium, thyroid hormone, buspirone, stimulant drugs (methylphenidate and modafinil), and atypical antipsychotics (olanzapine, quetiapine, aripiprazole, and risperidone). Additional studies used other augmentation strategies (yohimbine, atomoxetine, inositol, testosterone, and lamotrigine), or combinations with a second antidepressant (mianserin, mirtazapine, and desipramine). There was no evidence of clinical efficacy as measured by response in augmentation with buspirone, testosterone, methylphenidate, yohimbine, inositol, and atomoxetine. Although some studies of combined antidepressant therapy and lithium augmentation did show statistically significant clinical effects, results were inconsistent across studies. The only eligible study of thyroid augmentation was positive, though this study evaluated patients treated with tricyclic antidepressants. It is possible due to small sample sizes, that some of the trials failed to detect significant differences versus placebo because of inadequate statistical power. Adjunctive therapy with atypical antipsychotics showed higher response rates compared with antidepressant monotherapy and placebo but also had more withdrawals due to adverse events. Given ongoing concerns with the longer term tolerability and safety of the atypical antipsychotics, future research will need to investigate optimal duration of augmentation therapy in patients with major depressive disorder who do not respond to first line therapy.”
PMID: 19752841 [PubMed - in process]

And then there’s the reality to which most of us have been relegated. We don’t even get to see a doctor much less a psychiatrist. Usually some type of nurse, FNP, NP… who knows what and WHO KNOWS WHAT? Very likely, very little about mood disorders or psychiatric meds. So we probably get an SSRI and directions to return in a month. If we are not all better, which is rarely likely, we might get an increase in the dosage and directions to return in a month or two. If upon our return we are not all better were likely to just be ignored and told to come back in a month or two. So that’s somewhere between three and five months that an individual has been feeling terrible and hopeless- the fabric of their life deteriorating, jobs, relationships, goals, dreams. I wish I could tell you it’s probably going to get better right away, but probably not. On your next visit you are likely to be switch to another medication. Then if that doesn’t work, four or five weeks later, you get the next med increase. Not all better! That would put you in a category, along with 50% of patients with depressive disorders. If you’re lucky you’ll get a little lithium or you might get a thyroid panel. Of course, if you get the thyroid panel it will be more weeks before you get the augmentation, which you might not get any way because they might decide that your thyroid is fine, not understanding that your thyroid is not the point of treatment. Time slips away, months, six months, a year-and you still feel like S____. The current system creates suicide candidates.