Clinical inquiries: How should you manage a depressed patient unresponsive to an SSRI?

The best approach among studied alternatives to manage a patient with treatment-resistant depression is not clear from the evidence. All of the options reviewed seem to have about a 25% to 30% success rate. Switching to other antidepressants or augmenting with non-antidepressant drugs has the best supporting evidence (strength of recommendation [SOR]: B).1 Adding additional antidepressants (SOR: B), using psychotherapy (SOR: B), and initiating electroconvulsive therapy (ECT) (SOR: C) are options. Various antidepressants are used as add-on therapy. Psychotherapy is often recommended, though the evidence of benefit after a failed course of initial therapy is sparse. The evidence supporting use of ECT in treatment-resistant depression is weak. Comparison among the options is based on expert opinion (SOR: C). Additional reports from the STAR*D trial may improve the quality of the evidence in the near future.