1. Copyright Notice
This presentation is copyrighted by the Psychopharmacology Institute.
Subscribers can download it and use it for professional use.
The contents of the presentation may be modified, but the Psychopharmacology Institute logo must remain visible in all slides.

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

3. 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)

4. 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)

5. 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,

6. 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,

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

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

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

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

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

12. 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)

13. 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)

14. 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)

15. Next Presentation - Strategies: Combination and Augmentation