When to Adjust or Augment Antidepressant Treatment in MDD

When a patient does not respond fully to treatment for major depressive disorder (MDD), how can clinicians determine if augmentation is the best next step? 

In this video, Psych Congress PA Institute Co-Chair Erin Crown, MHS, PA-C, CAQ-Psychiatry, shares her approach to deciding when to augment rather than switch antidepressant therapy. 

With an emphasis on the importance of maintaining treatment adherence and avoiding a decline in response, Crown encourages clinicians to reconsider traditional medication sequencing strategies and recognize when augmentation may offer a more effective path to achieving remission sooner.

• MDD management should prioritize remission as early as possible because treatment response declines and treatment dropout increases with each subsequent treatment change. 
• Clinicians should re-evaluate routine sequential selective serotonin reuptake inhibitor (SSRI) treatment strategies and consider whether augmentation may be more appropriate than another antidepressant switch. 
• MDD patients with partial improvement and antidepressant tolerability may be appropriate candidates for discussing augmentation, with treatment decisions guided by evidence and shared decision-making based on patient preferences.

Erin Crown, MHS, PA-C, CAQ-Psychiatry: Hello, my name is Erin Crown, and I'm a psychiatric PA in State College, Pennsylvania, where I own my practice with my supervising physician. We provide outpatient medication management and psychotherapy. I've been leading a first-episode psychosis program since 2018. We have primary care, obesity medicine, aesthetics, and recently I've had opportunities to practice as a principal investigator in clinical trial work.

Psych Congress NP Institute: What clinical indicators or time points do you consider most critical in deciding that it's time to adjust or augment treatment in MDD? 

Crown: When we think about MDD and the impact that it has not only on the individual experiencing the symptoms, but on the lives of every life that that life touches, I think we really need to learn and shift into approaching MDD with a sense of urgency to work toward that ultimate goal of remission. This is obviously not going to be achieved for every patient, but it continues to need to be the goal ongoing no matter what. 

We have a lot of evidence that tells us that we must try to achieve that goal as early in the treatment course as possible because every time we make a treatment change, we get diminishing rates of response and we get increased rates of treatment drop out.

Using that information and tying it into this newfound sense of urgency in treatment, and working toward that goal of remission, has to be a fundamental shift in the way that we practice and think about this illness.

PCNPI: What are some common pitfalls that lead to delays in identifying when adjunctive therapy is needed?

Crown: I think sometimes we don’t have enough awareness about the evidence surrounding switching from one SSRI to another or, for example, from an SSRI to a serotonin and norepinephrine reuptake inhibitor (SNRI). Those are our practice habits, and the data tell us that for an individual in a depressive episode that's had at least 3 treatments in that episode, the most common sequence of treatment is SSRI1, SSRI2, SSRI3. 

That's not evidence-based treatment, but it is what we have been taught for many years. 

Additionally, I think that when we start someone on an antidepressant and they get a little bit better, but they don't reach their treatment goals, we start thinking about switching instead of augmenting. But I would argue that that is a perfect time to begin discussing augmentation—to build on the gains that we've made with that treatment that they're apparently tolerating because they're staying on it, and that they've had some improvements in their depressive symptoms instead of making a switch, especially if you're not going to make a mechanism-of-action switch. 

So, I think that we need to become more aware about the evidence around when to look at augmentation versus switching and some reasons around it and remember that we need to talk to our patient. What are their preferences? Do they want to take the risk of the loss of gains and are they going to tolerate the next thing? Or do they want to take the gains that they've gotten and add something on to try to get the additional improvement and work toward that remission goal?

Erin Crown, MHS, PA-C, CAQ-Psychiatry, is a Board Certified Physician Assistant with a Certificate of Added Qualifications in Psychiatry, and the Managing Member of Oasis LifeCare in State College, PA. She practices psychiatry in the outpatient setting and also leads a first episode psychosis program.. She is the owner of Future Options Research and is the Principal Investigator for multiple clinical trials. Erin is the past Chair of the NCCPA Health Foundation and is also working with AAPA and the PA Foundation to bring trauma informed education to school districts across the country.

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