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TOPICS TO REVIEW WITH PATIENTS WHEN CONSIDERING THE USE OF ANTIDEPRESSANTS

Over the course of one year, almost 10% of Americans experience a depressive disorder.¹ Most of these individuals do not seek help. The cost of not seeking help is borne in terms of increased rates of self-injury, prolonged symptomatic impairment, and decreased occupational functioning. Individuals who do not seek care for depression cite numerous reasons for this decision. These reasons include the stigma associated with mental illness, a belief that the symptoms are normal or minimal and will pass in time, a lack of insight, a fear of treatment, and the usual cost and access barriers.

Different hurdles face the individual who takes an affirmative step to confront his or her depression. Most people are highly ambivalent about seeking care for depression, even after making an initial appointment to discuss their mood. The physician should recognize the tenuous commitment to care at this point and make an active effort to incorporate this understanding into the first encounter. For example, the physician might, at some point during this first encounter, try to understand the patient’s ambivalence about seeking care. The physician might say, “Tell me a bit about how you decided to seek help for your mood”, or, alternatively, inquire, “Many people find this a difficult step to take; did you experience a similar feeling?” The practical effect of this brief interrogatory is a reduction of anxiety and a sense that the physician understands the patient. The same conversation also offers an opportunity for the physician to comment positively on the patient’s decision to seek care.

Psychiatrists explain this reluctance to engage care in terms of resistance, which, at least in part, is the patient’s unconscious effort to avoid a painful topic. If the physician fails to address the patient’s reluctance to engage in therapy, all future activities will be tainted by this unresolved ambivalence.

Naturally, once patients commit to treatment, a certain curiosity surrounds the treatment options. The level of intervention is related to the degree of impairment and the response to prior interventions, if any. Fortunately, many treatments, both pharmacologic and nonpharmacologic, are available. Many patients with depression receive care primarily in primary care settings. The choice of treatment in such settings is often limited to medication management. Such an approach is quite suitable for mild-to-moderate depression that is accompanied by a modest impairment in occupational or social functioning.

All antidepressants have roughly equal efficacy for moderate depression, which makes the specific medication choice a matter of tolerability, safety, and, sometimes, cost.² Physicians should become familiar with the safety and tolerability profiles of a few medications in each class. For example, the physician might choose sertraline as a representative medication of the selective serotonin reuptake inhibitors (SSRI). The advantages of sertraline include proven efficacy, lower risk of death from overdose, and a minimal impact on pharmacokinetic drug interactions.³ The latter characteristic is particularly important in reducing the risk of drug interactions in patients who take multiple medications.

Patients whose depression ranges from moderate to severe may benefit from an antidepressant with combined action that targets both the serotonin and noradrenergic system for reuptake inhibition. Venlafaxine is an antidepressant with this dual receptor inhibition. The efficacy of venlafaxine has been demonstrated as superior to that of SSRIs in the treatment of severe major depressive disorder, treatment-resistant depression, and depressive symptom remission. A bit more caution must be exercised with venlafaxine, given its propensity to elevate blood pressure and its slightly greater risk of fatal overdose as compared to that of an SSRI.⁴

An important consideration influencing medication choice is the patient’s prior response. If the patient had a favorable remission of depressive symptoms with a specific antidepressant, that medication is an obvious first choice. Similarly, a negative experience with a particular antidepressant suggests that an alternative medication should be prescribed.

The choice of medications is an important part of the plan to treat depression, but other factors also determine a favorable outcome. Patients should leave the physician’s office with a fairly clear expectation of what constitutes a reasonable response to treatment. The easiest approach is to carefully catalog the positive neurovegetative symptoms present at the beginning of treatment. Sleep difficulties are common, along with disturbances in appetite, energy, enthusiasm, and mood. The physician must be precise in quantifying the symptoms. For example, the physician should document the number of hours of sleep, the number of awakenings, the presence of disturbing dreams, and the “two hours spent worrying” before falling asleep. This quantitative assessment of a sleep disturbance becomes a useful way to document progress in therapy as sleep improves. A number of freely available depression rating instruments help convert the subjective mood experience into a more objective and measurable activity. The patient can actually chart his or her progress over time.

When patients are depressed, they naturally want immediate relief. The decision to seek care is accompanied by myriad expectations. Some patients expect an instantaneous cure, some expect the physician to assume total responsibility for the patient’s recovery, and some patients actually resist efforts to improve their mood. Part of the physician’s treatment efforts must be directed toward managing the patient’s expectations. For example, all antidepressants have a lag time of several weeks before they confer maximum benefit, assuming that the correct dose is prescribed, the patient is compliant, and he or she is not complicating treatment.

A common cause of a poor outcome in the treatment of depression is the presence of a comorbid disorder. Perhaps the most frequent undetected comorbidity that complicates recovery from depression is substance abuse. The physician must be vigilant in observing signs of alcohol and drug abuse. The use of tobacco is yet another complicating factor. Physicians and patients cannot expect a maximum response to treatment if comorbid substance abuse is neglected. The patient should also be encouraged to discuss any other prescriptions or over-the-counter medication he or she takes on a regular basis.

Medication is an important part of the treatment of depression, but the physician can decrease the time to recovery by providing psychotherapeutic treatment or referring the patient for such treatment. Patients whose depression ranges from moderate to severe often benefit from a referral to a psychiatrist who can use a broader array of complicated treatments.

The road to recovery is best paved with a good diagnostic assessment, an informed dialogue with the prospective patient, and a prudent discussion focusing on achievable outcomes. A referral to a psychiatrist may be warranted for patients who are resistant to treatment, those who respond inadequately to treatment, those who are otherwise medically complicated, or those whose mood disorder symptoms range from moderate to severe.

REFERENCES

1. National Institute of Mental Health. Depression. Available at: http://www.nimh.nih.gov/publicat/depression.cfm#ptdep1. Accessed September 26, 2006.

2. Anderson IM. Meta-analytical studies on new antidepressants. Br Med Bull. 2001;57:161-78.

3. McRae AL, Brady KT. Review of sertraline and its clinical applications in psychiatric disorders. Expert Opin Pharmacother. 2001;2(5):883-92.

4. Gutierrez MA, Stimmel GL, Aiso JY. Venlafaxine: a 2003 update. Clin Ther. 2003;25(8):2138-54.