Depressed patients with anxiety who fail initial antidepressant therapy may benefit from adding a second drug
Research Activities, July 2012, No. 383
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.