MDD: Switch vs Augmentation?

DESIGN: 

• Multisite randomized, single-blind, parallel-assignment trial.

INCLUSION CRITERIA:

• Suboptimal response to SSRI, SNRI or Mirtazapine.
• Suboptimal response = QIDS-C₁₆ score of >16 (after 6 weeks of treatment) or >11 (after 8 weeks of treatment) with 3 most recent weeks at stable “optimal” dose.

QIDS-C₁₆ = 16-Item Quick Inventory of Depressive Symptomatology-Clinician Rated.

EXCLUSION CRITERIA:

• current treatment with bupropion or any antipsychotic.
• history of bipolar disorder, schizophrenia, schizoaffective disorder, or other psychosis.
• current dementia
• eating disorder
• seizure disorder
• suicidal ideation requiring inpatient treatment
• unstable medical condition
• need of immediate psychiatric hospitalization
• substance dependence requiring detoxification in the past 30 days
• pregnant, lactating, or planning to become pregnant
• unable or unwilling to provide informed consent or declined to participate prior to randomization.

RANDOMIZATION: to one of the three treatment:-

• SWITCH GROUP: switch to bupropion sustained release.
• AUGMENT-BUPROPION GROUP: augment current treatment with bupropion sustained release.
• AUGMENT- ARIPIPRAZOLE GROUP: augment current treatment with aripiprazole. 

DOSE OF MEDICATIONS USED:

• SWITCH GROUP: dose of bupropion reached max of 200 mg twice daily by 6 weeks and remained at that level through 12 weeks. 
• AUGMENT-BUPROPION GROUP: also reached max of 200 mg twice daily by 6 weeks.
• AUGMENT- ARIPIPRAZOLE GROUP: dose of aripiprazole was 5 mg daily from weeks 2 through 10 and reached 10 mg daily at week 12. 

RESULTS:

(1) Remission rates at 12 weeks: Higher for Aripiprazole augmentation.

• Switch group: 22.3% (n = 114)
• Augment- bupropion group: 26.9% (n = 136)
• Augment- aripiprazole group: 28.9% (n = 146)

(2) Response rate:Higher for Aripiprazole augmentation.

• Switch group: 62.4%
• Augment- bupropion group: 65.6%
• Augment- aripiprazole group: 74.3%

(3) Side Effect Profile:

(A) Anxiety was more frequent in the bupropion augmentation group.

• Switch group: 24.3%
• Augment- bupropion group: 22.5%
• Augment- aripiprazole group: 16.6%

(B) Adverse effects more frequent in the augment-aripiprazole group included

• somnolence,
• akathisia, and
• weight gain. 

CONCLUSIONS:

Augmentation with aripiprazole resulted in a statistically significant but only modestly increased likelihood of remission during 12 weeks of treatment compared with switching to bupropion monotherapy.