Depressed patients with anxiety who fail initial antidepressant therapy may benefit from adding a second drug
Among patients who start treatment for depression, 40
percent will not respond to first-line therapy. One
factor contributing to treatment resistance may be the
presence of symptom clusters, such as anxiety,
insomnia, fatigue, or atypical features of depression.
Other researchers have found that anxiety, insomnia,
and loss of energy are the symptom clusters most
likely to influence the selection of an antidepressant
for a patient.
The current study examined the likelihood of
remission or response among patients with and
without symptom clusters whose second-line therapies
included augmentation with another medication or a
switch in medications. The investigators found that
patients' remission and response rates to alternative
second-line strategies—switching therapies or
augmenting therapy with a second agent—did not
differ for patients with coexisting atypical symptoms
or insomnia.
Patients with coexisting anxiety symptoms showed the
greatest difference in remission or relapse favoring
augmentation over switching, but the differences were
not statistically significant. Patients with low energy
were twice as likely to remit when they were
augmented with extended-release bupropion
compared to buspirone. If therapies were switched in
depressed patients with low energy, sertraline was
significantly more effective than venlafaxine.
The findings were based on applying propensity
scoring, a statistical technique, to analysis of data
obtained from the Sequenced Treatment Alternatives
to Relieve Depression (STAR*D) trial. This large
clinical trial compared the effectiveness of switching
and augmenting therapy strategies after failure with
the antidepressant citalopram. Three symptom clusters
(anxiety, insomnia, and loss of energy) were each
present in more than 50 percent of participants in
STAR*D. The study was supported in part by the
Agency for Healthcare Research and Quality
(Contract No. 290-2005-0041).
See "Does the presence of accompanying symptom
clusters differentiate the comparative effectiveness of
second-line medication strategies for treating
depression?" by Bradley N. Gaynes, M.D., M.P.H.,
Joel F. Farley, Ph.D., Stacie B. Dusetzina, Ph.D., and
others, in the November 2011 Depression and Anxiety
28(11), pp. 989-998.
— KB
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