Pharmacological augmentation in unipolar depression: a guide to the guidelines

Rachael Taylor, Lindsey Marwood, Emanuella Oprea, Valeria De Angel, Sarah Mather, Beatrice Valentini, Roland Zahn, Allan Young, Anthony Cleare

Research output: Contribution to journalReview articlepeer-review


Background: Pharmacological augmentation is a recommended strategy for patients with treatment-resistant depression (TRD). A range of guidelines provide advice on treatment selection, prescription, monitoring and discontinuation, but variation in the content and quality of guidelines may limit the provision of objective, evidence-based care. This is of importance given the side effect burden and poorer long-term outcomes associated with polypharmacy and TRD. This review provides a definitive overview of pharmacological augmentation recommendations by assessing the quality of guidelines for depression and comparing the recommendations made.
Methods: A systematic literature search identified current treatment guidelines for depression published in English. Guidelines were quality assessed using the AGREE II tool. Data relating to the prescription of pharmacological augmenters were extracted from those developed with sufficient rigour, and the included recommendations compared.
Results: 1696 records were identified, 19 guidelines were assessed for quality, and 10 were included. Guidelines differed in their quality, the stage at which augmentation was recommended, the agents included, and the evidence base cited. Lithium and atypical antipsychotics were recommended by all 10, though the specific advice was not consistent. Of the 15 augmenters identified, no others were universally recommended.
Conclusions: This review provides a comprehensive overview of current pharmacological augmentation recommendations for major depression and will support clinicians in selecting appropriate treatment guidance. Although some variation can be accounted for by date of guideline publication, and limited evidence from clinical trials, there is a clear need for greater consistency across guidelines to ensure patients receive consistent evidence-based care.
Original languageEnglish
JournalInternational Journal of Neuropsychopharmacology
Early online date13 May 2020
Publication statusE-pub ahead of print - 13 May 2020


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