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Algorithm-Based Treatment Shows High Lack Of Response To Selective Serotonin Reuptake Inhibitors

Almost half of patients with a unipolar and non-psychotic major depression will not respond to initial selective serotonin reuptake inhibitor treatment, Israeli clinicians report.

This finding, using algorithm-based treatment, indicates that the severity of depression may be an important predictor of response, say Dr Ofer Agid and Dr Bernard Lerer, and colleagues, from the Department of Psychiatry, Hadassah - Hebrew University Medical Center, Jerusalem.

Clinicians face a dilemma treating patients with a major depression: there is a wide choice of antidepressant medication and a lag time before they become effective. Choosing the right antidepressant can help patients minimize symptoms and help with compliance. "Unfortunately, there is very little evidence upon which to base such a decision," they add.

This led the researchers to devise a treatment algorithm for non-psychotic, unipolar major depression. It includes progression from a SSRI, usually fluoxetine, from 20 mg to 40 mg among patients who do not respond initially.

Patients unresponsive to an SSRI receive augmentation with triiodothyronine (T3, 25 to 50 [mu]g). All interventions are over a fixed period of time and are guided by overall clinical improvement as defined by the Clinical Global Inventory.

Among 81 patients who commenced open-label treatment with fluoxetine 20 mg; and 9 patients who received paroxetine, at four weeks, 74 completed treatment, and 44 (48.9%) responded to the regimen.

Only 5 patients (16.6%) responded when the SSRI dose was raised to 40 mg for a further two weeks. Patients who did not respond to SSRI treatment were significantly more depressed at baseline, and reflected by rating scales scores.

When the clinicians added T3, they found it was effective among 10 out of 16 women patients (62.5%), but was not effective in any of the 9 male patients who received it. Although values were within the normal range, patients who responded to T3 had higher serum thyroid-stimulating hormone levels than those who did not.

The effect of T3 may be related to thyroid function even within the normal range, clinicians conclude.
Int J Neuropsychopharmacology 2003;6:41-49. "Algorithm-based treatment of major depression in an outpatient clinic: clinical correlates of response to a specific serotonin reuptake inhibitor and to triiodothyronine augmentation"

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