Tuesday, July 11, 2017

Augmentation With Aripiprazole Found Superior When MDD Patients Don't Respond

Augmentation of antidepressant treatment with aripiprazole showed a modest but statistically significant advantage in terms of both remission and response over switching to bupropion in a population of predominantly male veterans with treatment-resistant depression.

That’s the finding from the VA Augmentation and Switching to Improve Depression (VAST-D) Study reported today in JAMA. Lead author Somaia Mohamed, M.D., Ph.D. (pictured left), of the VA Connecticut Healthcare System and colleagues cautioned that further cost-effectiveness analysis is needed given the small effect size and adverse effects associated with aripiprazole.

In comments to Psychiatric News, Mohamed said that since only a third of patients benefit from their first antidepressant treatment, clinicians typically have to choose a new medication on the basis of trial and error. “This study presents the first data indicating that adding an antipsychotic may be more effective than switching to a new antidepressant,” she said. “This study may encourage clinicians to try antipsychotics earlier than they might have otherwise.”

The study was a a multisite randomized trial with Veterans Health Administration (VHA) patients whose condition was unresponsive to at least one course of antidepressant treatment meeting minimal standards for dose and duration. Patients at 35 VA medical centers were randomized to one of three treatments: switch to another antidepressant, bupropion sustained release (switch group); augment current treatment with bupropion sustained release (augment-bupropion group); or augment current treatment with an antipsychotic, aripiprazole (augment-aripiprazole group).

Rates of remission (defined as absence of symptoms) at 12 weeks were 22.3% for the switch group, 26.9% for the augment-bupropion group, and 28.9% for the augment-aripiprazole group. Response (defined as 50 percent reduction in symptoms) was greater for the augment-aripiprazole group (74.3%) than for either the switch group (62.4%) or the augment-bupropion group (65.6%).

In an accompanying editorial, Maurizio Fava, M.D., said the VAST-D study extends findings of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. “Because the VAST-D study was implemented solely in VA sites, the population studied was predominantly male (85%), a significant difference from the usual study population in large trials of MDD, in which women typically far exceed the proportion of male study participants, as was the case with STAR*D,” he wrote.

Accordingly, the study cannot determine whether the results would have been different in a predominantly female population of patients with MDD. However, a pooled analysis of two trials comparing aripiprazole augmentation with placebo augmentation among patients with MDD and inadequate response to antidepressant therapy found that aripiprazole augmentation was actually more effective for women than men. This argues that the VAST-D study may have underestimated the relative benefit of aripiprazole augmentation.”

For information about VAST-D, see the Psychiatric News article “Study to Answer What Comes Next When MDD Patients Don't Respond.”


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