Thanks for the interesting article, which brought up several interesting topics. First, as a clinician, I found it interesting to look at a study from this perspective, rather than purely safety, tolerability, or efficacy metrics. This was refreshing, but I found it somewhat problematic that only aripiprazole, an SGA, and bupropion, and NDRI, were studied (however this is reasonable because they used existing data from VAST-D). I would be curious to see how lithium, buspirone, and thyroid hormone compare. One excellent point that came up during the discussion was the variability of cost from healthcare system to healthcare system. In the case of the VA, where VAST-D took place, aripiprazole is available at a substantially reduced price compared to many community and private practice setting. The extremely wide variabiltiy in healthcare/drug costs in our multifaceted American healthcare system has a huge confounding impact on any cost-effectiveness study without an impeccably-controlled approach and indeed greatly reduces the generalizabiltiy of the findings of this study to more general practice settings. For me, the take away was really that bupropion, at a much lower price in most healthcare settings, is basically as cost-effective as aripiprazole as an augmentation strategy for TRD. To me as clinician, that says go with bupropion first, unless there is another great reason to use aripiprazole (which might be more a function of severity/psychotic features, rather than treatment-resistance per se).
An interesting read, best with grains of salt, and a good discussion! I look forward to future meetings.