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Antidepressant Combinations Prof. Philip Cowen Professor of Psychopharmacology Department of Psychiatry University of Oxford, UK

Antidepressant combination Widely used but scant evidence base

Antidepressant combination Widely used but scant evidence base Mirtazapine + SSRI or SNRI Different MOA: broader neurotransmitter spectrum Carpenter LL, Yasmin S, Price LH. A double-blind, placebo-controlled study of antidepressant augmentation with mirtazapine. Biological psychiatry. 2002 Jan 15;51(2):183-8.

Antidepressant combination Widely used but scant evidence base Mirtazapine + SSRI or SNRI Different MOA: broader neurotransmitter spectrum Bupropion + SSRI or SNRI (common in the US) NA and DA enhancement

Antidepressant combination Widely used but scant evidence base Mirtazapine + SSRI or SNRI Different MOA: broader neurotransmitter spectrum Bupropion + SSRI or SNRI (common in the US) NA and DA enhancement Low evidence base STAR*D : adding bupropion was better than adding buspirone on some secondary outcome measures Trivedi MH, Fava M, Wisniewski SR, et al (2006) Medication augmentation after the failure of SSRIs for depression. New England Journal of Medicine, 354: 1243–52.

Antidepressant Combinations Start at a low dose Decrease in risk of drug interactions Mirtazapine 15 mg/day Bupropion 150 mg/day

Antidepressant Combinations Start at a low dose Decrease in risk of drug interactions Mirtazapine 15 mg/day Bupropion 150 mg/day If low dose is well tolerated and effective Increase towards a normal dose Watch out for side effects and drug interactions

Key Points Based on pharmacological reasoning, clinicians often use two specific antidepressant combinations: Mirtazapine + SSRI or SNRI Bupropion + SSRI or SNRI

Key Points Based on pharmacological reasoning, clinicians often use two specific antidepressant combinations: Mirtazapine + SSRI or SNRI Bupropion + SSRI or SNRI Limited evidence

Key Points Based on pharmacological reasoning, clinicians often use two specific antidepressant combinations: Mirtazapine + SSRI or SNRI Bupropion + SSRI or SNRI Limited evidence Start at low doses

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