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Strategies: Switching Antidepressants Prof. Philip Cowen Professor of Psychopharmacology Department of Psychiatry University of Oxford, UK

Switch to a different treatment No response to first line medication No difference between a drug with same MOA or a different one No response to first line medication (generally an SSRI)

Switch to a different treatment No response to first line medication No difference between a drug with same MOA or a different one No response to first line medication (generally an SSRI)

STAR*D Trial Failure to respond to citalopram Switch to Results: Very similar response rates Switch to Second SSRI: Sertraline SNRI: Venlafaxine NDRI: Bupropion Failure to respond to citalopram Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, Warden D, Niederehe G, Thase ME, Lavori PW, Lebowitz BD, McGrath PJ (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR* D report. American Journal of Psychiatry 163, 1905-17.

STAR*D Trial Failure to respond to citalopram Switch to Results Very similar response rates Switch to Second SSRI: Sertraline SNRI: Venlafaxine NDRI: Bupropion Failure to respond to citalopram Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, Warden D, Niederehe G, Thase ME, Lavori PW, Lebowitz BD, McGrath PJ (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR* D report. American Journal of Psychiatry 163, 1905-17.

Switching from fluoxetine Active metabolite with a long half-life Wait a week before starting another serotonergic drug Burden of 5-HT uptake blockade

Switching from fluoxetine Active metabolite with a long half-life Wait a week before starting another serotonergic drug Burden of 5-HT uptake blockade

Older antidepressants Effective in patients who have not responded to newer SSRIs or SNRIs Consider amitriptyline Consider MAOIs

Older antidepressants Effective in patients who have not responded to newer SSRIs or SNRIs Consider amitriptyline Consider MAOIs

Older antidepressants Effective in patients who have not responded to newer SSRIs or SNRIs Consider amitriptyline Consider MAOIs

Key Points When a first-line SSRI fails, most guidelines suggest switching to another antidepressant Switching within the same class or to a different class: little impact in outcomes If treatment resistant, consider switching to: TCAs (amitriptyline, clomipramine) MAOIs ( tranylcypromine)

Key Points When a first-line SSRI fails, most guidelines suggest switching to another antidepressant Switching within the same class or to a different class: little impact in outcomes If treatment resistant, consider switching to: TCAs (amitriptyline, clomipramine) MAOIs ( tranylcypromine)

Key Points When a first-line SSRI fails, most guidelines suggest switching to another antidepressant Switching within the same class or to a different class: little impact in outcomes If treatment resistant, consider switching to: TCAs (amitriptyline, clomipramine) MAOIs ( tranylcypromine)

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