Outcome of a 4-Step Treatment Algorithm for Depressed Inpatients
J Clin Psychiatry 2006;67(8):1266-1271
© Copyright 2014 Physicians Postgraduate Press, Inc.
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Objective: The aim of this study was to examine
the efficacy and the feasibility of a 4-step treatment algorithm
for inpatients with major depressive disorder.
Method: Depressed inpatients, meeting DSM-IV
criteria for major depressive disorder, were enrolled in the
algorithm that consisted of sequential treatment steps (washout
period, antidepressant monotherapy, lithium addition, treatment
with a nonselective monoamine oxidase inhibitor,
electroconvulsive therapy). Definition of nonresponse and
progression through the steps of the algorithm was dependent on
the score on the 17-item Hamilton Rating Scale for Depression
(HAM-D) at predefined evaluation times. Patients were admitted
from April 1997 through July 2001.
Results: Of the 203 patients studied, 149 were
treated according to the full algorithm, and 54 patients were
immediately entered into step 3. Of the 203 patients, 165 (81%)
achieved response (> = 50% reduction in HAM-D score) and 101
(50%) remitted (final HAM-D score < = 7). Of the 149 patients
treated according to the full algorithm, 129 (87%) responded and
89 (60%) remitted. Twenty-four patients (16%) dropped out from
Conclusion: Although response with
antidepressant monotherapy was less than 50%, successive
treatment according to the 4-step algorithm was very effective in
a sample of depressed inpatients. The adherence to the algorithm
was good as shown by a low dropout rate. This study emphasizes
the importance of persisting with standardized antidepressant
treatment in patients who are initially nonresponders to the
first antidepressant. By the end of the study, more than 80% of
the patients responded and 50% achieved full remission.