Expert Perspectives on Advances in the Management of Major Depressive Disorder - Episode 14

Switching Treatment vs Augmenting Strategies in MDD

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Experts in psychiatry review factors to consider when deciding to switch or augment treatment in major depressive disorder [MDD].

Andrew J. Cutler, MD; Greg, I know Sagar has talked a bit about this, but maybe you could help us understand at what point do you think about switching or starting a new treatment? And at what point would you augment?

Gregory Mattingly, MD: It’s one of the mysteries of what we do in clinical practice. And I don’t think there’s a right or a wrong answer. If you’d asked me 20 years ago, I would’ve quite often started something new. A lot like Sagar, I’ve become a fan of augmentation strategies more and more over the course of my practice. A kind of multimodal of treatments, and those augmentation strategies can be more than 1 medicine, augmenting with exercise, augmenting with psychosocial interventions, all of those things are augmentation strategies. Going back to some of the trials we talked about earlier, knowing that a medicine works by itself is really important, but knowing that medicine can work on top of another medicine is an equally important message for my patients.

I may have a patient who’s on a traditional antidepressant, maybe an SSRI [selective serotonin reuptake inhibitor], and they’ve done pretty well, but now the depression has come back. The patient’s reluctant to give up the medicine that’s worked for them pretty well over the last several years, but they know they need something extra. I don’t think there’s a right or wrong. I think it’s important to know when you can augment and when you can start a new treatment option. I think if we see zero benefit, obviously we’re going to start something new. I think if we see an intolerable adverse effect, we’re going to start something new. It’s that group in the middle, they’re partially better, but not all the way better. And quite often I like that option of being able to augment something on top.

Andrew J. Cutler, MD: That certainly makes sense, and I love what you said about involving the patient, again, in this decision. After all, they may have a preference, they may have a value in this. They may think that adding another medicine means that there’s something wrong with them or they’re weak somehow. I think it’s just always critical to get their buy-in and get their point of view on that.

Transcript edited for clarity