Clinical Question

Is augmentation of antidepressant treatment effective for patients with treatment-resistant depression?

Bottom Line

The available evidence that treatment-resistant depression (depression that is unresponsive to two different treatments of adequate dose and length) responds well to augmentation treatment (i.e., adding psychotherapy, lithium, or aripiprazole [Abilify] to current treatment) is weak. The available evidence shows no benefit with lithium and small benefit with psychotherapy or aripiprazole. (Level of Evidence = 1a–)

Synopsis

The authors searched two databases (but not the Cochrane Library) for randomized studies of augmentation treatment for patients who did not respond to at least two courses of treatment for major depressive disorder. Two authors selected studies for inclusion and independently extracted the data. Most of the 28 studies of 5,461 patients had low to moderate risk of bias (i.e., studies were of medium to high quality) and included both drug treatment and psychological therapies. Instead of comparing directly across treatments (the benefit in one group vs. the other), the authors compared the before-after change in results within each group. In three low-quality studies, psychological treatment showed a moderate benefit. In four studies of aripiprazole, there was a small likelihood of benefit after short-term treatment (effect size = 1.33; 95% CI, 1.23 to 1.44) compared with placebo. Lithium produced an effect size similar to placebo.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Government

Setting: Various (meta-analysis)

Reference: Strawbridge R, Carter B, Marwood L, et al. Augmentation therapies for treatment-resistant depression: systematic review and meta-analysis. Br J Psychiatry. 2019;214(1):42–51.

Editor's Note: Dr. Shaughnessy is an Assistant Medical Editor for AFP.