Switch or Stay? Knowing When a Partial Response Is Worth Building On

This episode, "Switch or Stay? Knowing When a Partial Response Is Worth Building On," features the panel weighing when to switch medications versus building on partial progress.

Dr. Citrome lays out his personal rule for switching medications: he only switches when there is no benefit whatsoever, when side effects are genuinely problematic, or when a patient says outright that they don't want to keep taking a drug, which he interprets as a signal that they've already stopped. When he does switch, he asks what the patient liked and didn't like about the prior medication, since every agent carries some side-effect burden and none is perfect. He weighs activation, sedation, weight gain, and sexual dysfunction risk before recommending a next choice, framing the decision as a calculated bet the two of them make together, with an explicit commitment to follow up closely.

Staying the course and building on existing treatment, he explains, applies when a patient shows directional improvement without intolerable side effects. He describes this as not wanting to throw out a foundation that is already partly working. Early in his career, before evidence-based augmentation options existed, he tried a wide range of add-on agents, including lithium and thyroid hormone, with unpredictable results. That changed once second-generation antipsychotics became available as adjunctive options; six agents are now FDA-approved for this indication, one specifically for treatment-resistant depression, and the remaining five differ meaningfully from one another despite sharing a similar label.

As with switching, he asks patients which side effects concern them most and which they can tolerate, while also weighing practical access, since some agents are branded and harder to obtain while generics may be easier to prescribe but less well tolerated. Dr. Harding briefly reflects that early prescribing habits often mirror what a trainee's attending physicians modeled, until growing confidence and experience lead clinicians to branch out into newer options on their own.

Up next, in "Why Generic Antidepressant Cycling Falls Short: Early Augmentation and TD Risk," Erin Crown, MHS, PA-C, CAQ-Psychiatry explains why she often moves early to a different mechanism or to augmentation when initial treatment falls short.