Augmentation Therapy for Patients with Major Depression

Cincinnati—For patients with major depressive disorder (MDD) who do not adequately respond to initial treatment with antidepressant therapy (ADT), combination with another ADT is the most common augmentation therapy used by clinicians. Clinicians are more likely to augment initial ADT with atypical antipsychotics for patients with severe depression compared with those with mild symptoms.

These are the conclusions of a study presented during a poster session at the AMCP meeting. The poster was titled Utilization of Augmentation Agents for the Treatment of Depression: Analysis of a Psychiatric Electronic Medical Record Dataset. Researchers undertook the study to examine real-world utilization of treatment augmentation for MDD in psychiatric clinical practice.

Current guidelines from the American Psychiatric Association recommend treatment augmentation for patients with MDD who fail to achieve adequate response to an initial ADT after 4 to 8 weeks of treatment.

Using a psychiatric electronic medical record (EMR) dataset, the investigators identified and retrospectively reviewed data on 3209 patients with MDD who received augmentation therapy for depression between January 2001 and June 2011. Augmentation therapy was defined as a combination of antidepressants or an antidepressant plus an atypical antipsychotic, mood stabilizers/anticonvulsants, or stimulants.

All patients included in the study had a diagnosis of depression without psychosis/psychotic features, were ≥18 years of age, and had initiated adjunctive therapy for depression. Patients were excluded from the study if they had other conditions that may warrant augmentation therapy, had a clinical global impression-severity score of 1 or missing on the index date, had used any of the augmentation agents or combination therapy prior to the index period, had the index visit in an inpatient setting, and did not receive any antidepressant in the 12-months prior to the index period.

Of the 3209 patients in the study, most where white (70.7%) and >31 years of age (77.3%), 30.2% were male, most had a diagnosis of recurrent MDD (58.5%), many were diagnosed with moderately severe depression (47.9%) and were also diagnosed with an anxiety disorder (47.8%), and most received augmentation therapy in an academic center (54.1%) or community mental health center (32.7%).

The study found that the choice of augmentation treatment in most patients (75.4%) was a combination of ADTs, followed by atypical antipsychotics (11.1%), mood stabilizers/anticonvulsants (8.3%), and stimulants (5.2%).

For patients who received combination ADTs, a selective serotonin reuptake inhibitor (SSRI) plus bupropion was the most common combination (23.1%) followed by an SSRI and atypical SSRI (15.9%). Quetiapine or aripiprazole were the most common atypical antipsychotic augmentation treatment used by 39.6% and 31.2% of patients, respectively; gabapentin and lamotrigine the most common mood stabilizers/anticonvulsants used in 39.1% and 21.4%, respectively; and methamphetamine and dextroamphetamine the most common stimulants used in 55.7% and 35.3%, respectively.

Compared with patients with mild depression symptoms, patients with severe depression symptoms were 2.75 times more likely to receive an atypical antipsychotic than a combination of ADTs, 3.35 times more likely to receive a mood stabilizer, and 4.05 times more likely to receive a stimulant.

Augmentation with an atypical antipsychotic was also more likely in male patients, nonwhite patients, and those with concomitant psychiatric diagnoses.

According to the investigators, the main limitation of the study was the potential lack of comprehensive healthcare information in an EMR database. Another possible limitation of the database is that it is specific to specialty psychiatric providers, which may have limited the results of the study to be generalized to treatment patterns in the primary care setting.

This research was supported by Bristol-Myers Squibb and Otsuka Pharmaceutical Co., Ltd.