Partial Response in MDD: Optimize, Switch, Combine, or Augment

This episode, "Partial Response in MDD: Optimize, Switch, Combine, or Augment," features the psychiatry panel examining the decision clinicians face most often.

Dr. Alva asks Dr. Clayton to work through four levers available for a partial responder, and whether a genuine partial response argues for building while a flat non-response argues for a switch.

Dr. Clayton anchors her answer to a number. If a patient has less than a 20% response in the first two to four weeks, the likelihood of reaching remission is almost zilch. Measurement-based care is what makes that visible. Below 20% or 25%, she considers switching reasonable, and she wants it done earlier. If the patient is already at a therapeutic dose, she says, recognize that and do not wait eight weeks. She prefers switching mechanisms where possible rather than moving within a class. A clinician might start with an atypical antidepressant, or arrive there after an SSRI, driven partly by safety and partly by insurance. Between 20% and 50%, she says, augmentation becomes the reasonable lever, since a 50% response is not the goal. She has used thyroid for many years and reaches for lithium when something feels like mood instability. She does not want those forgotten, while noting antipsychotics carry the approved designation for augmentation.

Dr. Alva then raises the 2023 CANMAT update, which placed dextromethorphan-bupropion as a second-line option, and asks Dr. Oyedeji where she puts it. She notes those guidelines come out of Canada, and calls second-line placement reasonable but conservative. The first-line lane is a crowded playground of monoamine agents, and comparing a new agent to drugs marketed for decades is not a fair contest. She returns to early intervention and meeting patients where they are. Access, however, is critical. She works in a community mental health space, where newer does not mean accessible, so she leverages evidence for prior authorization and uses samples.

In "Discontinuing Antidepressants in MDD: Timing, Tapering, and Relapse," Dr. Clayton will make the case that stopping a medication deserves as much rigor as starting one.