Practice recommendations
- Combined treatment with psychotherapy or psychiatric consult and drug therapy has shown better response in several studies than either therapy alone (A).
- Although not proven by clinical trials, selecting a medication by matching its side-effect profile to patient characteristics is supported by case reports and likely enhances compliance.
- Patients who do not improve with initial therapy often benefit from being switched to another class of antidepressants (A), or having a drug from another class added to their therapy (B).
You are more likely to see depression in your practice than any other disorder except hypertension.1 Given the prevalence of depression* and the variability of its clinical symptoms and comorbidities, how do you determine the optimal therapy for a given patient?
A sobering thought: nearly half of all patients stop taking their antidepressant prescription medication within the first month of treatment.1 We discuss the critical factors you can address to help patients stick with treatment and achieve the best outcome.
Therapeutic Options
Pharmacotherapy
Antidepressants are thought to exert their therapeutic and adverse effects through 3 chemical monamine neurotransmission systems; by increasing levels of norepinephrine, serotonin, or dopamine in the synapse; and by resultant secondary changes in presynaptic and postsynaptic receptor physiology.3,8,9 Newer medications—such as selective serotonin reuptake inhibitors (SSRIs)—have simpler dose schedules, different (and for some patients more favorable) adverse effect profiles, and less likelihood of causing death from overdose compared with older tricyclic antidepressants (TCAs) and monamine oxidase inhibitors (MAOIs).
Patients are less likely to discontinue treatment with SSRIs than with TCAs (odds ratio=1.21; 95% confidence interval [CI], 1.12–1.30).10
However, there are no clinically significant differences in effectiveness between SSRIs and TCAs (strength of recommendation [SOR]: A).11 Importantly, although practice patterns in the use of antidepressants have changed, some reasons for the preference of newer effective agents have not been substantiated. For instance, we do not know whether the patient population taking newer agents has a lower rate of suicide, despite the difference in fatality risk mentioned earlier.
Combined pharmacotherapy and psychiatric consultation
Combining pharmacotherapy and psychotherapy can be more effective than either modality alone. In one study, 73% of patients with chronic depression treated with combination therapy showed a reduction of 50% or more on the Hamilton Rating Scale for Depression (HRSD), compared with just 48% in the nefazodone-only and psychotherapy-only groups (SOR: A). Among those who completed the study, the rates of response were 85%, 55%, and 52%, respectively (although the results considered compliant patients only, which biases the results in favor of treatment).2
Among elderly depressed patients who received home care, 58% of those who underwent intervention by a psychogeriatric team recovered, compared with just 25% in the control group (SOR: A).12 The intervention group received a multidisciplinary team evaluation and an individualized management plan, which could include any combination of physical, psychological, or social interventions. The control group received usual care from their general practitioner.
Studies of combination therapy have yielded mixed results, but guidelines from the psychiatric literature based on clinical experience advocate concomitant psychotherapy and medication (SOR: A).13 For patients with persistent symptoms after 6 to 8 weeks of taking antidepressant medication, concomitant psychotherapy improved compliance, satisfaction, and outcomes when compared with usual care.14
The burden of depression
At any one time, at least 3% of the US population suffers from chronic depression.2 More than 17% of the population have had a major depressive episode in their lifetime, and more than 10% have experienced an episode within the past 12 months.3 The incidence and prevalence of depression in women are approximately twice that seen in men.4
Major depression is the fourth leading cause of worldwide disease burden.5
Natural history and prognosis
An untreated episode of depression usually lasts 6 months or longer. About half of persons experiencing major depression will have a second episode; a second episode increases the risk for a third episode to 80%.1,3 Patients diagnosed with depression average 5 depressive episodes in their life and may have recurrences every 4 to 6 years. Episodes usually become longer and more frequent with advancing age. In about 20% to 35% of cases, only partial remission occurs and functioning remains impaired.1
Fifteen percent of severely depressed patients commit suicide. The 2 most powerful predictors of suicide are a history of major depression or schizophrenia and a history of addictive disorders.6
Outpatient treatment of depression has increased markedly in the United States, with greater involvement on the part of physicians, greater use of psychotropic medications, expanding availability of third-party payment, and less use of psychotherapy.7