Pharmacological choices after one antidepressant fails: a survey of UK psychiatrists

Abstract

Background: At least 30% of depressed patients fail to respond to adequate first-line anti-depressant medication. Several pharmacological strategies have been suggested to treat such refractory depression. There has been no survey of United Kingdom psychiatrists' treatment preferences for refractory depression. This study was carried out to determine both experience and preference of various strategies for management of refractory depression. Method: A total of 300 fellows, members and inceptors of the Royal College of Psychiatrists were randomly selected and approached by postal questionnaire. They were asked to comment on management of a detailed clinical vignette of a case of depression with initial treatment failure. Results: The response rate was 63% ( n=175). The most popular treatment choices were increasing dosage of tricyclic medication and change of medication to SSRI. The most rarely selected were augmentation with triiodothyronine (T3) and augmentation with tryptophan or MAOIs. Treatment choice was significantly influenced by previous experience. A large number (39%) of psychiatrists were not confident in treating refractory depression. Conclusion: Surprisingly few psychiatrists chose to use the best proven pharmacological treatments such as augmentation with lithium or T3. In view of this and the considerable proportion of psychiatrists lacking confidence in the management of refractory depression, this topic deserves priority as a topic for continuing professional development (CPD) courses.