Combining Antidepressants When Treating Depression

Following his Psych Congress 2019 presentation on drug combinations in major depressive disorder, Michael Thase, MD, discussed the strategy of combining antidepressants when treating patients with depression.

Dr. Thase is Professor of Psychiatry, Perelman School of Medicine, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.

He will give a presentation on adjunctive and combination therapies for depression at Elevate by Psych Congress, being held March 27-29 in Las Vegas, Nevada.   

Read the transcipt:

It's funny to think about the history of combining antidepressants because when I first learned how to prescribe antidepressants, it was a marker of a bad practitioner. There was just no good reason to do this, except some very elite ultra-experts might sometimes combine monoamine oxidase inhibitors and tricyclics.

The newer generation of antidepressants have such safety advantages compared to the older that they often can be combined with almost no increased risk and very similar tolerability to monotherapy.

I think when you do this, the evidence suggests that you should try to use full therapeutic doses of the first and the second antidepressant. You should be mindful of the possibility of drug-drug interactions.

The combining agents of first choice really reflect the fact that we're often looking for something to help patients with sleep and appetite. When that's the case, mirtazapine is the preferred combiner. Or, we're trying to help the person with energy, motivation, possibly even libido or sex drive. Then bupropion is the first choice.

There's really good meta-analytic evidence for mirtazapine having additive antidepressant effects. The evidence from controlled studies is less certain for bupropion, although it is such a widely used strategy by psychiatrists in particular. I think there must be some advantage for it that's not adequately reflected in the studies.