Effect of Clinical Decisions in Patients with Major Depressive Disorder with an Inadequate Response to Initial Treatment with an Antidepressant

The decision to increase the current dose of medication or switch to another prescription can impact outcomes and health resource utilization.

Major depressive disorder (MDD) is one of the most common mental diseases in the general population, with an estimated annual prevalence of 5.7%.

Although “the introduction of newer-generation antidepressants has improved our ability to treat depression,” only 35-40% of patients will experience a remission of symptoms during an initial eight-week trial. The authors of “Assessment of pharmacological strategies for management of major depressive disorder and their costs after an inadequate response to first-line antidepressant treatment in primary care”, published in the August 2012 issue of the Annals of General Psychiatry, studied the treatment choices available to clinicians and patients following an inadequate response to initial therapy to determine “the most common treatment strategies and their costs for patients with an inadequate response to first-line antidepressant in primary care.”

The team of researchers analyzed health records of 2,260 adult patients in a large primary care health center in Spain. To be eligible for the study, patients had to have a diagnosis of major depressive disorder according to the International Classification of Primary Care and have received at least eight weeks of treatment with an antidepressant (but not within the previous six months). Patients were organized into two groups: patients with an inadequate response to initial antidepressant (AD) treatment (no remission), and patients in remission after the first AD treatment. Patients were followed for up to 12 months.

Forty-three percent of patients had an inadequate response to initial treatment; 57% were in remission. The average age of participants was 58.8 years. Women made up nearly three-fourths (74%) of the study cohort. The most common comorbidities in the study group were dyslipidemia (43.6%), high blood pressure (34.2%), and fibromyalgia (25.2%).

The authors reported the following data regarding treatment choices for the management of inadequate initial response to treatment with antidepressants: 43.2% of patients were switched to another AD, 15.5% were given an additional AD, the dose of the initial AD was increased in 14.6% of patients, and 26.7% continued to receive treatment with the same dose of the same antidepressant agent. The mean time until a change in strategy was 6.5 months.

Patients with an inadequate AD response had worse percentages of treatment compliance and treatment persistence at 12 months. Patients with an inadequate initial response to treatment with antidepressants had more office visits per year compared to patients in remission (16.8 vs. 11), missed more work days (20 vs. 12.8), and had higher annual direct health care costs (826 vs. 451 Euros).

The authors concluded that these findings demonstrate that the therapeutic strategy most commonly used in primary care “for the management of patients with MDD and an inadequate response to first-line treatment is switching to a different antidepressant drug. In addition, there was a significant delay in change of strategy.” They advise clinicians to “carefully reevaluate patients presenting partial response to AD treatment and to adopt a faster change of pharmacological strategy.”