uestion: How urgent is the need for relief of the depression?
uestion: How urgent is the need for relief of the depression?
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Help: The purpose of this question is to differentiate those patients who could take the time to switch to a monotherapy with a different first-line antidepressant, either a different SSRI or bupropion SR, and which patients should perhaps be offered a more aggressive but somewhat more risky approach in terms of side effects, namely with augmentation or with switching to a drug with more significant potential side effects than one of the first-line options.
The success rate with switching among SSRI's after the first has failed or produced intolerance is generally quite high in the literature. Two studies¹,² suggest the success rate is greater than 50%. One study³ found it to be only 26%, but these were inpatients, and the outcome was measured on six month follow-up. Two other papers described 63% response rates, one involving switches from sertraline to fluoxetine, and one from fluoxetine to citalopram (the latter a 12 week study).(4,5) The success rate with switching from an SSRI to bupropion SR, or vice-versa, is not so easily culled from published evidence, but seems comparable to the SSRI to SSRI switch.
¹Brown W, Harrison W. Are patients who are intolerant to one SSRI intolerant to another? J Clin Psychiatry 1995; 56:30-34.
²Sacchetti E et al. Are SSRI antidepressants a clinically homogeneous class of compounds? Lancet 1994; 344:126-127.
³Zarate CAJr et al. Does intolerance or lack of response with fluoxetine predict the same will happen with sertraline? J Clin Psychiatry 1996; 57:67-71.
(4)Thase ME et al. Fluoxetine treatment of patients with major depression who failed initial treatment with sertraline. J Clin Psychiatry 1997;58:16-21.
(5)Thase Me, Feighner JP, Lydiard RB. Citalopram treatment of fluoxetine nonresponders. J Clin Psychiatry 2001;62(9):683-7.
It would be worthwhile to try a second SSRI or bupropion SR. An SSRI trial, to be considered adequate, should be a total of at least 8 weeks in duration and should explore different doses if response is unsatisfactory, including a period on the maximum recommended dose if tolerated. (If you choose "no" above and go on to a recommendation to try an SSRI, a more detailed dosing strategy will be offered.)
Nefazodone would be a good choice if you want to avoid sexual side effects or if dizziness would not be a side effect which could be a special hazard for the patient (e.g. if employed as a window washer). But, the new black box warning makes nefazodone, for the most part, a choice only when patients have not tolerated other antidepressants. Click on nefazodone for a discussion of the issues.
Bupropion SR also has infrequent sexual side effects, is more stimulating, and at doses up to 300 mg has much less seizure risk compared to the regular-release formulation.
Recommendation #02
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