Section Free - Video Lectures

11. GAD Pharmacotherapy: Augmenting vs Switching in Partial Responders

Published on May 23, 2018 Expired on April 1, 2021

David Osser, M.D.

Associate Professor of Psychiatry - Harvard Medical School

Key Points

If the patient seemed to have a partial response and side effects were acceptable, think about whether this improvement was more likely due to placebo effect rather than a real medication effect
- Get patient input
- If you conclude it was placebo, do not augment but instead switch (go to Node 4)
The three augmenters that seem the most likely to help and be reasonably safe are hydroxyzine, pregabalin, and benzodiazepines

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Transcript

We come now to node 3B. 3B is when you have tried your SSRI, our first-line treatment and you got a partial response.
They’re somewhat better. Should you try augmenting with something or switch? This is a problem one has in a lot of psychopharmacology whether it’s for depression or PTSD. So you could consider augmentations. The three that we’re going to discuss that you could use for that purpose are hydroxyzine, pregabalin or a benzodiazepine. But we do not recommend a second-generation antipsychotic until the third trial because of the side effects that they have.

References

Abejuela, H. R., & Osser, D. N. (2016). The Psychopharmacology Algorithm Project at the Harvard South Shore Program: an algorithm for generalized anxiety disorder . Harvard review of psychiatry, 24(4), 243-256.
Baldwin, D. S., Waldman, S., & Allgulander, C. (2011). Evidence-based pharmacological treatment of generalized anxiety disorder . International Journal of Neuropsychopharmacology, 14(5), 697-710.
Rickels, K., Shiovitz, T. M., Ramey, T. S., Weaver, J. J., Knapp, L. E., & Miceli, J. J. (2012). Adjunctive therapy with pregabalin in generalized anxiety disorder patients with partial response to SSRI or SNRI treatment . International clinical psychopharmacology, 27(3), 142-150.
Pollack, M. H., Van Ameringen, M., Simon, N. M., Worthington, J. W., Hoge, E. A., Keshaviah, A., & Stein, M. B. (2014). A double-blind randomized controlled trial of augmentation and switch strategies for refractory social anxiety disorder . American Journal of Psychiatry, 171(1), 44-53.
Fava, M., Rush, A. J., Alpert, J. E., Balasubramani, G. K., Wisniewski, S. R., Carmin, C. N., … & Warden, D. (2008). Difference in treatment outcome in outpatients with anxious versus nonanxious depression: a STAR* D report . American Journal of Psychiatry, 165(3), 342-351.
Altamura, A. C., Serati, M., Buoli, M., & Dell’Osso, B. (2011). Augmentative quetiapine in partial/nonresponders with generalized anxiety disorder: a randomized, placebo-controlled study . International clinical psychopharmacology, 26(4), 201-205..
Brawman-Mintzer, O., Knapp, R. G., & Nietert, P. J. (2005). Adjunctive risperidone in generalized anxiety disorder: a double-blind, placebo-controlled study . The Journal of clinical psychiatry, 66(10), 1321-1325.
Pollack, M. H., Simon, N. M., Zalta, A. K., Worthington, J. J., Hoge, E. A., Mick, E., … & Oppenheimer, J. (2006). Olanzapine augmentation of fluoxetine for refractory generalized anxiety disorder: a placebo controlled study . Biological Psychiatry, 59(3), 211-215.

Next Section

12. Try a Second SSRI or an Alternative (Node 4)