Beating the Blues
Beating the Blues
Abstract & Commentary
By Eileen C. West, MD, Director of Internal Medicine Women's Health, Clinical Associate Professor of Internal Medicine, University of Oklahoma College of Medicine, Oklahoma City. Dr. West reports no financial relationship to this field of study.
Synopsis: The American College of Physicians has just published a new clinical practice guideline on the use of second-generation antidepressants in treating depressive disorders.
Source: Qaseem A, et al. Using second-generation antidepressants to treat depressive disorders: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2008;149:725-733.
Ever wonder which drug to reach for first in treating a clearly depressed clinic patient? The choices abound and selection can seem ambiguous for many providers. It turns out there is good reason for it. The Clinical Efficacy Assessment Subcommittee of the American College of Physicians addresses the topic of antidepressant medications in the November 18 issue of Annals of Internal Medicine. They review 203 studies from 1980 to 2007 and reach a few helpful conclusions.
Their summary focuses on second-generation antidepressants (SSRIs, SNRIs, and SSNRIs), as these are more commonly used and have been shown to have similar efficacy and lower toxicity in overdose than the first-generation tricyclic antidepressants and monoamine oxidase inhibitors. Psychotherapy, cognitive behavioral therapy, and other nonpharmacologic treatments are not addressed.
Commentary
Depressive disorders affect 16% of adults in the United States during their lifetime with an economic burden estimated at $83.1 billion. Depressive disorders include major depressive disorder (MDD), dysthymia, and subsyndromal depression including minor depression. Typically the course of depression is characterized by three phases: acute (6-12 weeks), continuation (4-9 months), and maintenance (1+ year). Relapse is the term used for the return of depressive symptoms during the acute or continuation phases. Recurrence refers to a return of depressive symptoms during the maintenance phase, which is considered a new, distinct episode.
So, which medications work best to treat acute depression, which most effectively treat symptom clusters such as anxiety, insomnia, and pain, and which had the worst side effects? The answers may be surprising. Of the twelve drugs reviewed, all work with about the same effectiveness, and most have similar side effects! (Shhh! Don't let the drug companies hear us say that.) OK, there are a few minor differences. Mirtazapine works faster than an SSRI in the acute phase. Paroxetine is associated with increased rates of sexual dysfunction while bupropion is associated with a lower rate of sexual adverse events. SSRIs result in an increased risk for nonfatal suicide attempts compared to placebo. There is weak evidence suggesting bupropion may be associated with increased risk for seizures and venlafaxine may be linked to increased risk for cardiovascular events. Nefazodone may be associated with increased risk for hepatotoxicity (again, weak evidence).
Unfortunately, 38% of the patients did not achieve a treatment response during 6-12 weeks of treatment and only 46% of patients achieved full remission with any of the second-generation antidepressants. The committee sounded an urgent plea for further research.
Ultimately four recommendations on treatment of depression with a second-generation antidepressant were made:
1. When choosing pharmacologic therapy to treat patients with acute major depression, select second-generation antidepressants on the basis of adverse effect profiles, cost, and patient preferences.
2. Assess patient status, response to drug therapy, and adverse effects of antidepressant therapy on a regular basis beginning within 1-2 weeks of starting medication.
3. Modify treatment if the patient does not have an adequate response within 6-8 weeks of initiation of therapy for major depressive disorder.
4. Continue treatment for 4-9 months after a satisfactory response in patients with a first episode of major depressive disorder. For patients who have had 2 or more episodes of depression, a longer duration of therapy may be beneficial.
The American College of Physicians has just published a new clinical practice guideline on the use of second-generation antidepressants in treating depressive disorders.Subscribe Now for Access
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