Augmentation and Combination Strategies

Augmenting an antidepressant with another drug is an important option in helping achieve remission, a number of speakers pointed out at the American Psychiatric Association annual meeting held in Philadelphia in May. Augmenting carries forward a partial response from an antidepressant and buys time, Andrew Nierenberg MD of Harvard and Associate Director of the Mood Disorders Program at Massachusetts General Hospital noted in one symposia. It also helps avoid discontinuation, may achieve a more rapid response, and can be used to treat breakthrough symptoms. Holly Swartz MD of the University of Pittsburgh in addition observed that augmentation may result in synergy while Richard Shelton MD, chief of the Adult Psychiatric Division at Vanderbilt, mentioned the possibility of lowering doses and expanding therapeutic effect. On the minus side are cost issues, the uncertainties of dosing, and the possibility of drug-drug interactions.

Unfortunately most of what we know is based on a small number of open studies and anecdotal reports. "There is not enough data," Dr Swartz cautioned. Dr Nierenberg alluded to the phenomenon of the "augmentation of the month club" where once you have a study involving five patients, "everyone does it."

Augmentation strategies include:

• Lithium - 60 published studies, all but three involving TCAs, slow onset of action, side effects "burdensome", starting to drop in popularity.

• Thyroid (T3) - Equal to lithium with TCAs, anecdotal case reports with SSRIs.

• Buspar - Very little data, may improve sexual dysfunction, may speed up response of SSRI.

• Pindolol - May speed up response of SSRI.

• Viagra - May counter SSRI sexual dysfunction side effect.

• Stimulant and Dopamine Agonists (Mirapex, etc) - No data.

• Anticonvulsants- Evidence for bipolar depression.

• Provigil - Novel psychostimulant, one small study.

• Zyprexa - A study on treatment-resistant depression patients taking a Zyprexa-Prozac combination found a response as early as week one. Eli Lilly may have a combination Zyprexa- Prozac pill on the market in 2003.

• Risperdal - Eight case reports.

• Estrogen - Case reports of women responding.

• Potential augmenters - Inositol (naturally occurring in the brain), SAMe, EPA (found in omega-3), folate.

COMBINATIONS

Combinations tend to involve two different classes of antidepressants, such as an SSRI with an antidepressant that works on norepinephrine (such as Effexor, with a dual serotonin-norepinephrine action, plus a weaker dopamine action). One controlled study of patients who had not responded to an SSRI showed a 64 percent response when treated with an SSRI-Remeron combination (Remeron has a unique action that works on both serotonin and norepinephrine).

Go To Page: 1 2 3