Treatment choice after one antidepressant fails: a survey of northeastern psychiatrists.

BACKGROUND

Because limited evidence exists to help clinicians choose the next step after a depressed patient fails to respond to an adequate trial of an antidepressant, I conducted a survey to explore psychiatrists' treatment choices.

METHOD

I asked 118 northeastern psychiatrists what they would do next in response to a clinical vignette of an inpatient with DMS-III-R major depression who failed to respond to 4 weeks of nortriptyline at adequate blood levels.

RESULTS

Lithium augmentation was chosen by more than a third (33.9%) of psychiatrists. Other choices, in order of decreasing frequency, were continuing nortriptyline for another 2 weeks (17.8%) and switching to either fluoxetine (16.1%), electroconvulsive therapy (11.0%), or a monoamine oxidase inhibitor (6.8%). Only one psychiatrist each chose thyroid augmentation or bupropion.

CONCLUSIONS

The surveyed psychiatrists overwhelmingly preferred lithium augmentation over other strategies to manage treatment-resistant depression. Research on comparative strategies is lacking and urgently needed.