Skip to main navigation
Skip notifications
Access to POEMs and Essential Evidence Plus will no longer be included in CMA membership as of Dec. 1, 2023.
Search
Weak evidence supports augmentation therapy for treatment-resistant depression
Clinical Question
What is the evidence for augmentation therapy in patients with treatment-resistant depression?
Bottom line
There is weak research to guide treatment decisions for patients who have not responded to 2 adequate courses of antidepressant treatment. One study of cognitive behavioral therapy showed benefit over placebo. Aripiprazole (Abilify) had a small effect, but neither antipsychotics nor lithium provided benefit over placebo. 1a
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Government
Setting: Various (meta-analysis)
Synopsis
These investigators searched 2 databases (but not Cochrane CENTRAL) to identify randomized controlled trials, in any language, that investigated the benefit of augmentation therapy in patients with depression despite 2 attempts at treatment of adequate duration. The authors followed PRISMA guidelines for conducting systematic reviews. They identified 28 studies: 25 investigated additional pharmacotherapy, and 3 investigated psychological therapies. The studies were of moderate to high quality. There was considerable heterogeneity across the study results attributed to different treatments, duration of study, and study quality. Cognitive behavioral therapy was more effective than placebo in a single study, but other counseling interventions were not. Treatment with antipsychotics or lithium was not more effective than placebo. Aripiprazole had a small likelihood of producing benefit (effect size 1.33; 95% CI 1.23 - 1.44).
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
All this time
So all this augmentation not that great. CBT maybe helpful, but which other psychological therapy not helpful would be good to know.
What is the harm likelihood of augmentation.
Any thoughts about ect, or newer ideas of reset brain with psychedelic agents. This upends my ideas of treating treatment-resistsnt depression. How often is the diagnosis incomplete or incorrect? Psych keeps getting harder.
SR/MR of "pre-post effect size" ???
I found the underlying paper virtually unintelligible. Is this a new term "pre-post effect size" based on looking at the difference from baseline in treatment group only, versus the conventional approach in RCT of comparing means or categorical ratings in treatment groups vs. comparators or placebo??? Even after years of reading RCT and SR/MA and Cochrane Reviews, this one baffled me. I had just been looking at the brexpiprazole studies (Thase et al) and found very little difference from placebo, and this review appears to show less difference or less "ES" with brexpiprazole than with aripiprazole ... does this show us that brexpiprazole (now being marketed) is inferior to aripiprazole, or more that neither really do anything useful for such patients? I would be very interested to know more from whomever submitted the POEM!
Tom Perry MD, FRCPC
Vancouver (no conflicts)