A five-member expert panel reviewed two network meta-analyses of the atypical antipsychotics approved in the US as add-on treatment for major depression after an inadequate antidepressant response.
The panel judged the two analyses broadly concordant despite differing methods, and did not endorse any particular agent. Its emphasis was on considering an effective adjunct earlier where appropriate, and choosing among them by tolerability and patient characteristics rather than small efficacy differences.
This is expert opinion built on meta-analyses rather than new trial data. Long-term, head-to-head and phenotype-specific evidence is still missing, so the choice remains individual.
- Choose an adjunct on side-effect profile — weight, metabolic effects, akathisia, sedation
- Check baseline weight, glucose and lipids before starting and monitor them
- Ask about restlessness at each early review, as akathisia is often missed
- Set a review point to stop the adjunct if there is no response
Why it matters
Small efficacy differences between adjuncts matter less than the side effects each patient can live with.
Don't overread it
This is a consensus discussion of existing meta-analyses, not a new comparative trial.
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