Formulary Strategy and the Evidence Gaps Still Facing MDD Add-On Therapy

In "Formulary Strategy and the Evidence Gaps Still Facing MDD Add-On Therapy," Dr. Citrome closes out the series by looking at formulary strategy and what evidence is still missing.

Asked how payers should approach formulary design and utilization management given this evidence base, Dr. Citrome argues that, ideally, all five adjunctive antipsychotics would be available without prior authorization or fail-first requirements, since the right choice varies by individual patient. He acknowledges that payers will likely impose some utilization controls regardless, driven by cost pressures rather than clinical nuance. In practice, he says it's not unreasonable to ask a treatment-naive patient to try a well-tolerated generic first, understanding that not every patient will respond or tolerate it well. Dr. Citrome describes his own prescribing philosophy as using every available piece of information, including comparative effect sizes and tolerability data. He advocates for the option most likely to succeed for that specific patient, while acknowledging his predictions are sometimes wrong in either direction. Looking ahead, he identifies a significant open question in the evidence base: how long a patient should remain on an adjunctive atypical antipsychotic. What the relapse or recurrence risk looks like after stopping also remains unknown. That data doesn't yet exist for adjunctive use in major depressive disorder, in contrast to the maintenance evidence already available for antipsychotics used in schizophrenia and bipolar disorder. Closing the interview, Dr. Citrome leaves viewers with a direct recommendation: read these meta-analyses in their original published form rather than relying on secondhand summaries. For those unfamiliar with how to interpret a meta-analysis, he points to available tutorials. He argues that this literacy will only become more important as head-to-head trials remain unlikely, and as network meta-analyses increasingly fill the resulting evidence gaps in everyday decision-making.

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