Description
Objective: To evaluate the comparative effectiveness of treatment augmentation, switching, or dose escalation for inadequate treatment response among patients living with depression. Methods: We conducted a retrospective cohort study using data from the Medicare Current Beneficiary Survey(MCBS; 2016-2022). We identified beneficiaries with depression who had both survey responses and had at least one antidepressant claim record 6 months before the outcome assessment. We excluded patients diagnosed with bipolar disorder, schizophrenia, and other psychotic disorders. Patients with evidence of treatment resistance, determined by using 3 or more antidepressants, or any antipsychotics at baseline, were also excluded. The primary outcome was the proportion of patients in remission, defined as a Patient Health Questionnaire (PHQ-8) score <5 at 12-week follow-up. Interventions of interest were three guideline-recommended modification strategies:(1) dose escalation;(2) switching; or(3) augmentation, which is determined based on changes of treatment at 3 months compared to 6 months preceding the outcome assessment. We estimated the average treatment effect using augmented inverse probability weighting (AIPW) and also included population-representative survey weights for estimation. Sensitivity analyses, including an 8-week follow-up, or restricted to beneficiaries aged 65 or older, were conducted. Results: A total of 187 eligible patients were included in the analysis. Sixty-eight people (n=68, weighted%: 40%) switched treatment, 71(33%) had dose escalation, and 48(27%) had augmented treatment. The AIPW estimated difference between augmentation and dose escalation groups is -6.3% (95% CI: -28.6% to 16.1%), switching and dose escalation groups is -0.9% (95% CI: -21.2% to 16.1%), and switching and augmentation groups is 5.4% (95% CI: -15.6% to 26.4%). When the 8-week follow-up period was applied, the estimated difference between the augmentation and dose escalation groups was -19.9% (95% CI: -40.6 to 0.7%), while other sensitivity analyses showed indifference between dose escalation and switching, or between switching and augmentation. Conclusion: The primary results showed no significant difference in the proportion of remission among the three guideline-recommended strategies. Given the absence of significant differences, treatment modifications should focus on tailoring treatments to clinical needs and patient preferences, prioritizing factors such as minimizing adverse events and improving treatment accessibility to optimize adherence.
Publication Info
2026.