Clinical inquiries. What's best when a patient doesn't respond to the maximum dose of an antidepressant?

First, consider possible causes of the inadequate response to an antidepressant, then weigh treatment options in light of the characteristics of the individual patient and therapy. When managing a patient with nonpsychotic depression and inadequate response to the maximum dose of a single antidepressant, the physician should first identify factors that may contribute to the poor response, such as suboptimal dosage resulting from nonadherence, inadequate duration of therapy, and comorbid medical and psychiatric conditions. The literature supports several treatment alternatives, including augmentation with cognitive therapy, switch therapy, and combination-augmentation therapy; not enough studies exist to recommend the best treatment. All options reviewed produced a 20% to 50% remission rate. Physicians should consider the patient's clinical history and preferences, along with drug toxicity, potential drug interactions, and cost when making treatment decisions.