Switch ineffective antidepressants

Depressed patients who do not respond to initial SSRI treatment should be offered the choice of additional medication or a different antidepressant, US research has suggested.

The study found that one in three depressed patients who did not achieve remission using one antidepressant became symptom-free when given additional medication, while one in four achieved remission after switching to different drugs.

The findings are based on the STAR*D study, funded by the US National Institute of Mental Health. In this, 1,439 adults with a non-psychotic major depressive disorder who did not respond to 12 weeks' treatment with citalopram (Cipramil) were assigned to receive extra therapy or to switch treatment.

Of these, 727 were assigned to change to 14 weeks' treatment with up to 400mg daily of noradrenaline and dopamine reuptake inhibitor bupropion (Zyban), 200mg daily of the SSRI sertraline (Lustral), or 375mg of combined serotonin and noradrenaline reuptake inhibitor venlafaxine (Efexor).

About 25 per cent of patients in all groups achieved remission after switching and no difference was found in outcomes, tolerability, or adverse events.

In another arm of the trial, 565 patients were assigned to continue on 55mg daily citalopram plus up to 400mg daily bupropion or 60mg daily of SSRI enhancer buspirone (Buspar). About 30 per cent of patients in both groups achieved remission after an average 6.3 weeks, with no significant differences in side-effects, or adverse events.

North Shields GP Dr Dave Tomson, who has an interest in mental health, said: 'The evidence for switching depressed patients to a different drug if they don't respond early to treatment is convincing.'

NICE recommends switching if there is no response to initial SSRI treatment after a month.

- N Engl J Med 2006;354:1,231-52

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