Short and long-term treatment outcomes of stepwise psychopharmacotherapy based on early clinical decision in patients with depressive disorders

Background: To investigate the effects of stepwise pharmacotherapy based on early clinical decision-making on shortand long-term treatment outcomes in outpatients with depressive disorders in a naturalistic one-year prospective design. Methods: Patients were recruited at a University hospital in South Korea from March 2012 to April 2017. At baseline, 1262 patients received antidepressant monotherapy. For patients with an insufficient response or uncomfortable side effects, next treatment steps (1, 2, 3, and 4 or over) with alternative strategies (switching, augmentation, combination, and mixtures of these approaches) were administered considering measurements and patient preference at every 3 weeks in the acute treatment phase (3, 6, 9, and 12 weeks) (N=1246), and at every 3 months in the continuation treatment phase (6, 9, and 12 months) (N=1015). Remission was defined as a Hamilton Depression Rating Scale score of <= 7. Results: Remission was more frequently achieved with increasing treatment steps and advanced treatment strategies over the treatment period, while the superior effect of treatment Step 4 or over no longer persisted in the continuation treatment phase. Augmentation + combination strategy was associated with the best outcome, with least benefit associated with a switching strategy compared to monotherapy continuation. Adverse events were more frequent with increasing treatment steps and advanced treatment strategies, while numbers of visits did not statistically differ by treatment steps or strategies. Limitation: The lack of a comparison group without early clinical decision due to the descriptive nature of study design limits to prove directly the study question. Conclusions: A stepwise pharmacotherapy approach based on early clinical decision-making in the light of measurements and patient preference could enhance both shortand long-term treatment outcomes in depressive disorders.