, Volume 11, Issue 3, pp 175-180
Date: 29 Aug 2012

Substitution Therapy in Patients with Major Depression

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Antidepressants are one of the most effective treatments for major depressive disorder. However, despite optimal treatment, a substantial number of patients, up to 50%, may have a partial or no response to the first antidepressant used. In such cases, several options are available. These include substitution of the first antidepressant with a second antidepressant, often of a different class, or various combination or augmentation strategies.

In general, substitution is a well tolerated and effective way of managing treatment-resistant depression. Switching to an alternative class of antidepressants usually increases the chances of treatment response, although with the selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs) a second trial may be attempted with the same class of drug. In general, a washout period between trials of different compounds is not necessary, except when first generation monoamine oxidase inhibitors are used. In that situation, an appropriate washout period is required when switching to or from this class of compound, particularly when switching to or from the SSRIs.

Further studies are required to determine the relative benefits of augmentation/combination versus substitution treatment of refractory depression.