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Outcome of a 4-Step Treatment Algorithm for Depressed Inpatients

J Clin Psychiatry 2006;67(8):1266-1271

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 the algorithm.

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.