which drug for which patient ? because a patient must wait weeks  according to some studies upwards of 12 weeks [ 1 , 2 ]  for an antidepressant to be effective for unipolar depression , and because the initial drug prescribed often benefits only about 50 - 70% of patients [ 3 , 4 ] , many patients continue to suffer from depression for significant time periods while waiting for an effective drug to be found .
current bases upon which the choice of an initial antidepressant is made include cost , side effect profiles , propensity for drug interactions , availability on formularies , physician preferences , severity of depression [ 5 , 6 ] , presence of psychotic features   and presence of a comorbid condition , such as attention - deficit hyperactivity disorder ( adhd ) , obsessive compulsive disorder ( ocd ) , and certain anxiety or substance abuse disorders [ 8 - 11 ] .
although physicians do consider certain symptoms reported by patients in selecting among antidepressants , usually the quality of the depression and the premorbid personality of the patient are not factors in drug selection .
there is currently no brief , office - based rating instrument designed specifically to determine which antidepressant medication should be given to which patient .
this paper proposes that patients who are particularly likely to respond to bupropion have certain premorbid personality characteristics .
they are hard - driving , " high - powered " individuals , often entrepreneurs or successful business people , who relate to life in terms of accomplishments and achievements .
by contrast , it is observed that patients who are most likely to respond to fluoxetine have different premorbid characteristics .
they rarely report exercise as meaning much to them , either in their premorbid state or when depressed , and their depression is not as connected with the notion of body movement .
they do not relate to life in terms of accomplishments to the same degree as do bupropion responders .
in addition to a different premorbid history , the fluoxetine - responding patients describe their depression with a different cluster of symptoms .
when they present for treatment , their depression has more " darkness " associated with it , more moodiness , more swings in mood , and they " cling " more .
increased irritability is often prominent . ruminating more often than bupropion responders , they often ask questions such as , " how do i get out of this ? " or state , " i see no way out of this . "
the premise of this paper is that bupropion - responding patients report depression in a characteristic way and selective serotonin reuptake inhibitor ( ssri)-responding patients report depression in a characteristic way , and the two ways are different .
 these patients often report a loss of something  of drive , of purpose .  
the above traits and symptoms are not reported to the same degree in ssri - responding patients , who seem to  fall into  something .
the ssri - responding patients often describe weepiness , mood changes , irritability , darkness , being  up and down ,   being in a pit ,  and self - esteem difficulties .
not all patients presenting for treatment of unipolar depression may be categorized as described , and many patients respond to either ssris or to bupropion .
the authors have noticed clinically , however , that when patients can be categorized as ssri or bupropion responders , the patients response to medication is more predictable and more complete , and the medication for that category becomes the drug of choice .  
this paper proposes using personality traits  not personality disorders per se  to guide antidepressant selection .
it identifies two characteristics that predispose to bupropion response  achievement orientation and history of response of mood to exercise .
the achievement orientation category is similar to the premorbid personality described by akiskal , as " hyperthymic temperament , " which he described as " very successful , eminent people  who run the world " .
akiskal describes these patients as over - talkative , extroverted , over - involved , uninhibited , " full of plans , " over - confident , irritable , cheerful , over - optimistic , exuberant , meddlesome and promiscuous .
the hyperthymic temperament , which is described as including habitual short sleep ( often three to four hours per night ) , seems much closer to hypomania or mania than are the traits described in this paper , however .  
the characteristic personality type associated in this paper with fluoxetine response is similar to the " depressive personality " described by various clinicians .
chronic pessimism , loneliness , dissatisfaction , guilt , feelings of inadequacy , and certain other characteristics common in " depressive personality " and chronic low - level depression may describe a more serotonergic subgroup of this disorder .
ravindran , et al   reported that " subaffective dysthymia , " a chronic depressive syndrome described by akiskal , seems to respond well to fluoxetine , which is similar to the authors findings .
kramer   believes that rejection sensitivity responds to fluoxetine , which also coincides with this report .
there are similarities between the above observations of bupropion - responding patients and bipolar ii patients .
however , the hypomanic episode required for diagnosis of bipolar ii disorder is described as an  unequivocal change in functioning that is uncharacteristic of the person when not symptomatic  in dsm 4-tr , in contrast to this paper s describing long - term traits .   the premorbid high - energy level that this paper associates with bupropion response has some similarity to adhd .
this paper is not , however , simply promoting better diagnosis of adhd , as it reports other traits predicting bupropion response , such as exercise response .
furthermore , the authors observe that many bupropion responders in their premorbid condition , in contrast to adhd patients , were highly focused ; it is only in their depressed state that these patients experienced impaired concentration .
one author ( dsb ) developed a 10-question , self - administered rating scale , the fluoxetine bupropion assessment scale ( fbas ) , to further assess these traits and the observed correlation .
after the scale had been utilized to guide treatment in one author s practice for several years , it was decided to retrospectively review charts in this psychiatrist s practice to see if use of the scale had improved patient outcomes .
it was hypothesized that use of the fbas by a psychiatrist to select an antidepressant for patients had improved treatment outcomes .   in the scale , questions 1 - 5 evaluated traits which were hypothesized to predict bupropion response .
the first two questions examined the importance of exercise in the pre - depressed state and mood response to exercise .
while exercise has health benefits for most patients , only some individuals report an " endorphin release " or mood benefit from exercise , while others simply feel tired afterward .
this paper postulates that exercise - responding patients are biochemically different and are likely to respond to bupropion , possibly because bupropion causes a mild increase in dopamine and norepinephrine , neurotransmitters which increase during exercise . in the scale ,
questions 3 and 4 were designed to assess achievement orientation ; question 5 asked about hyperactivity , which could include either adhd , which in some studies has shown a limited response to bupropion treatment [ 19 , 20 ] or simply pre - depression high energy , which the authors also postulate is associated with bupropion response .
questions 6 - 10 assessed symptoms of depression hypothesized to indicate fluoxetine response : rumination , feelings of  darkness  , tendency to  cling  to others , or a feeling that other people do not meet one s interpersonal needs . because the authors describe the fluoxetine - responding traits more as rumination than as hopelessness per se ,
not all postulated fluoxetine - responding traits could be included in a scale of this brevity  self - esteem difficulties and irritability were not assessed .
for ease of scoring , the questions were designed so that low numerical answer scores ( 0 - 2.5 ) would indicate fluoxetine response , and high scores ( 3 - 5 ) would indicate bupropion response .
thus , for some questions , the answer ,  a great deal  would score  5 ,  and on other questions ,  not much  would score  5 . 
charts for this retrospective study were screened by clerical staff at the outpatient office of one author ( dsb ) .
one before the psychiatrist was informed of the above - stated theory by another author ( wms ) , and the other after he was informed of the theory , developed the fbas , and began administering and using it to guide treatment .
staff utilized scheduling books , accounting records , and examination of current and stored charts to create a sequential list , in order seen at the office , for each of the time periods , to obtain approximately 50 sequentially seen charts for each time period .
inclusion criteria included outpatients with depressive spectrum illnesses ( major depression or depression nos ) with beck depression inventory scores 17 , who were prescribed fluoxetine or bupropion as the initial drug prescribed by the psychiatrist .
patients with intake diagnoses of schizophrenia , bipolar disorder , obsessive compulsive disorder , or panic disorder were excluded from the study , as were patients with substance abuse in the two months prior to intake , and patients assessed to have depression due to a medical condition .
patients were excluded who had received fluoxetine or bupropion at any time prior to initial evaluation , or who had received any antidepressant treatment in the two months prior to their initial evaluation .
after the above - mentioned exclusions , there were 33 patients in the non - fbas group , of whom 42.4 % were male , with a mean age of 33.8 years . in the fbas - guided treatment group were 39 patients , 56.4 % male , with a mean age of 30.4 years .
charts meeting criteria were photocopied and prepared so that the reviewers were blinded as to the time period involved .
raters reviewed charts using clinical global impression ( cgi ) criteria to assess severity of illness , drug efficacy ( therapeutic effect / side effect ) and global improvement from clinical information in the charts .
the cgi rates treatment response as 0-not assessed , 1-very much improved , 2-much improved , 3-minimally improved , 4-no change , 5-minimally worse , 6- much worse , 7-very much worse . intent - to -
analysis was performed to determine if the physician utilized the fbas score for drug allocation during the fbas - guided treatment phase .
logistic regression was used to model drug allocation on each fbas item independently and on all items in a stepwise approach using a best - subset selection method . ordered logistic regression
because of the small number of patients in each cgi cell , the data were further analyzed by combining treatment responses into three larger groups by cgi score : good response ( 1 - 2 ) , minimal to no improvement ( 3 - 4 ) , and worse ( 5 - 7 ) .
it was hypothesized that individuals scoring high on the bupropion - oriented questions 1 - 5 would score low on the fluoxetine - oriented questions 6 - 10 , and vice - versa . to determine if the questionnaire did identify two separate groups of depressed patients , the two domains ( 1 - 5 and 6 - 10 ) were labeled and dichotomized as high or low based on the average score , and cross - tabulated .
the median score of the two groups was also used to dichotomize the two groups .  
the data were coded for this analysis the same way as in the questionnaire , in that a patient s strong endorsement of fluoxetine items results in a low numerical score on fluoxetine items , and a patient s strong endorsement of bupropion items results in a high score on bupropion items .
therefore , a high total score on the questionnaire was postulated to predict bupropion response and a low total score , fluoxetine response .
total fbas was a strong predictor ( p = 0.017 ) of treatment allocation , indicating that the physician did utilize the scale to determine which medication to prescribe .
the evidence is in the correct direction , but the data do not provide sufficient evidence at the 5% level to support the hypothesis that fbas - guided treatment allocation improves patient outcome as measured by efficacy or global improvement ( p = 0.175 and p = 0.128 , respectively ) .   however , the odds that a patient receiving fbas - guided treatment had a higher efficacy score were 76% greater than for a patient receiving a non - fbas - guided treatment . similarly , the odds that a patient receiving fbas - guided treatment had a greater global improvement score were 92% greater than for a patient receiving non - fbas - guided treatment ( table 1 ) .
similar results were obtained after adjusting for severity of illness ( efficacy p = 0.139 , global improvement p = 0.147 ) , and for differences in age , gender , and marital status ( efficacy p = 0.087 , global improvement p = 0.122 ) . when global improvement was reclassified into three groups based on the score : ( 1 - 2 , 3 - 4 , and 5 - 7 )
, the fbas - guided treatment group had a statistically significant improvement compared to the non - fbas - guided treatment group , at the 5% level ( p = 0.047 ) . to evaluate
if the questionnaire identified two separate groups , an analysis was performed for both the average and median trait scores for questions 1 - 5 ( bupropion - responding personality style ) and questions 6 - 10 ( fluoxetine - responding personality style ) .
these results are shown in table 2 ( for average trait score ) and in table 3 ( for median trait score ) .
this is a preliminary study , designed to see if an easily administered questionnaire based on premorbid traits and certain depressive symptoms could  improve the aim  of a psychiatrist in selecting an antidepressant .
the data were in the direction of better results in the fbas - guided group , particularly after adjusting for differences in age , gender , and marital status .
when global improvement data were grouped , there were statistically significant better results in the fbas - guided group .
the analysis for internal consistency , designed to evaluate if the questionnaire identified two different subgroups of patients , did not show that the questionnaire differentiated the two hypothesized groups , perhaps due to small sample size .
sample size was not sufficient to determine which individual questions were driving the overall tendency of the questionnaire to predict bupropion versus fluoxetine response .
some of the ten scale questions  numbers 4 and 5 in particular  may identify undiagnosed bipolar patients .
this seems unavoidable , as traits of bipolar disorder overlap traits of other diagnostic categories , including personality disorders .
since this study was performed , the scale has been revised to better assess premorbid traits .
the revision also assesses irritability and self - esteem , and quantifies exercise participation prior to the onset of depression .
the study was limited by the modest sample size , which diminished the statistical power to test the hypotheses related to efficacy and global improvement .
studies to validate the scale ( with akiskal s temps - a or cloninger s tci ) and a larger study initially randomized to treatment protocol , with subsequent randomization to fluoxetine and bupropion treatment in the non - fbas - directed group , are indicated .
replication of the study with a larger sample could better inform the relationship of fbas - guided treatment with efficacy and global improvement .
if these results are positive , the use of a brief , easily administered , office - based questionnaire could increase the likelihood that physicians will select the optimum antidepressant for patients , thus speeding patients recovery from depression .
after reading each question carefully , please circle the number corresponding to the answer which best describes your experience :
 this paper proposes that a certain premorbid personality type  that of hard driving , achievement - oriented , often exercise - oriented individuals  correlates with bupropion response ; conversely , patients without these premorbid traits and whose depression is marked by mood swings , irritability and rumination are likely fluoxetine responders . 
 the authors developed the fluoxetine bupropion assessment scale ( fbas ) , a 10-question , self - administered rating scale , to assess these traits and hypothesized that its use would improve outcomes . 
 a marriage and family therapist ( mft ) and a registered nurse / nurse practitioner ( rn / np ) retrospectively reviewed 72 charts from one psychiatrist s office for two time periods : before and after the psychiatrist utilized the questionnaire to guide antidepressant selection ( 33 charts before and 39 charts after ) . 
 raters were blinded to the theory and to the treatment time period . 
 on the basis of clinical information in the charts , they formulated clinical global impression assessments of treatment response in patients with beck depression inventory scores 17 who were not on either drug at the time of intake , and who were prescribed either fluoxetine or bupropion.the data were in the direction of better results in the fbas - guided group , particularly after adjusting for age , gender and marital status ( efficacy p = 0.087 ) . when global improvement data were combined into three groups describing treatment response ( improved , minimal to no improvement , and worse ) 
 there were statistically significant better results ( p = 0.047 ) in the fbas - guided treatment group . 
 revision and validation of the questionnaire and a larger , randomized study seem indicated . 
 