eMedicine Feature Series

Depression and Anxiety Newsletter _________________ Series 2, Issue 4, 2007

TOPICS TO REVIEW WITH PATIENTS WHEN CONSIDERING USE OF ANTIDEPRESSANTS

William R Yates, MD
University of Oklahoma College of Medicine

INTRODUCTION

To increase the chance of successful pharmacologic antidepressant therapy for patients with depression, clinicians should review several specific topics with their patients before the initiation of such therapy. Discussion points range from alternatives to pharmacologic therapy to common adverse effects of specific medications.

Clinicians can begin the discussion by soliciting specific aspects of the patient’s condition, including any previous experience with antidepressant therapy, the patient’s expectations for therapy, and any external sources of information regarding therapy. After establishing expectations and understanding the past history of the patient’s condition, alternatives to drug therapy may be considered and discussed.

If pharmacologic therapy is determined to be appropriate for the patient, the different classes of antidepressant therapy available should be discussed. This discussion includes each antidepressant’s expected duration of therapy, associated cost, and potential drug-drug interactions with other medications the patient may be taking. Adverse effects specific to the class of medication being considered should also be discussed. In the context of adverse effects and treatment goals, the importance of continuous monitoring and regular follow-up appointments for any required dosage adjustments or medical regimen changes should also be stressed.

PREVIOUS EXPERIENCE WITH ANTIDEPRESSANT THERAPY

First, a patient’s previous experience with and expectations of antidepressant pharmacologic therapy should be explored. The physician should begin by asking if the patient has previously been treated with an antidepressant. If the patient has had previous experience with antidepressants, questions regarding the quality of the response to treatment and experience with any adverse effects are advised. A patient who has previously responded positively to a specific antidepressant may experience a similar response during treatment of a subsequent episode of depression. Similarly, a significant history of intolerability with a specific antidepressant can predict future tolerability issues. Also, patients may request a specific antidepressant based on information obtained from family, friends, or other sources.

ALTERNATIVES TO ANTIDEPRESSANT THERAPY

Information regarding potential alternatives to antidepressant therapy should be reviewed. For patients with mild to moderate depression, a trial of psychotherapy alone can be considered. Such a trial should be paired with continued surveillance of the patient's depression by the clinician. Antidepressant therapy may be indicated later in the course of treatment if the depression worsens over time or if the response to psychotherapy is suboptimal.

ANTIDEPRESSANT TREATMENT OPTIONS

The major antidepressant treatment classes should be reviewed with the patient. The relative merits of each specific class of medications should be presented in a balanced discussion. Topics should include the expected goals of treatment, the anticipated duration of the course of therapy before the treatment objectives may be realized, the cost of the medication for the duration of the expected course, and the common and serious adverse effects associated with each class.

A review of the efficacy of antidepressant therapy prior to treatment is important. Clinicians should alert patients to the delayed treatment response often seen with pharmacologic antidepressant treatment. Although treatment commonly elicits at least a partial response after a period of treatment, complete remission of depression is more difficult to achieve. Complete remission may require dosage adjustment, switching to a different antidepressant, or drug augmentation. Such tailoring of treatment may require a time commitment of several months and a significant number of office visits.

The issue of treatment cost is important to many patients, and patients often appreciate an estimate of the cost before filling a prescription. Clinicians should ask about the patient's prescription coverage benefits and note any prescribed antidepressants that are not covered. Patients without insurance coverage may benefit from a referral to a community mental health agency or an assessment of eligibility for pharmaceutical company patient assistance programs.

Review with the patient the common adverse effects for each antidepressant that is under consideration. The transient nature of some adverse effects should be mentioned, and tolerability should be carefully reviewed at each visit. Depression is commonly associated with low self-esteem, feelings of hopelessness, and, sometimes, suicidal ideation. Suicidal ideation may worsen with antidepressant therapy, and patients should be instructed to contact their clinicians if suicidal ideation emerges or worsens. Antidepressant-associated changes in suicidal ideation appear to be more common when doses are initiated or changed. Potential antidepressant effects on sexual interest and function should also be discussed. Patients should be given contact information for the clinician's office in case any unexpected or serious adverse effects arise prior to the next follow-up visit.

DRUG-DRUG INTERACTIONS

The clinician should review the patient's current medication list for any potential interactions with the added antidepressant. Patients may be reluctant to discuss antidepressant use with other medical team members, but they should be encouraged to inform all prescribers of the addition of an antidepressant to their medication list. Questions about future prescription compatibility with the patient's antidepressant drug should be addressed to the antidepressant prescriber.

CHANGING DOSAGE OR DISCONTINUING MEDICATION

Patients may experience overt or subtle pressure from friends or family members about the potential problems with antidepressant treatment. The clinician should advise the patient to not change antidepressant dosage or discontinue antidepressant therapy without medical review. Although decreasing the dosage of a medication may reduce any adverse effects the patient is experiencing, patients should not discontinue medication without consulting with the physician. One specific reason for this approach is that rapidly discontinuing certain antidepressant medications may produce withdrawal symptoms, recurrence of depression or anxiety, or both.

TYPICAL MONITORING PATTERN FOR RESPONSE AND ADVERSE EFFECTS

The importance of regular follow-up visits to monitor response and tolerance to pharmacologic therapy and to make any necessary dosage adjustments should be stressed to patients. Some additional phone contact may be necessary between visits. Other depression treatment options may need to be considered for patients who do not respond to antidepressant treatment or do not respond completely. Patients should not cancel appointments even if they are feeling better.

The timeline for ongoing care and monitoring of the patient's depression is best outlined at the time of treatment initiation. However, the actual duration of therapy may need to be tailored to the patient's response to treatment, the previous history of the patient’s disease, the severity of the depression at the time of therapy, drug tolerability, and interest in discontinuation. A careful review of these topics with the patient, both at the time of treatment initiation and on an ongoing basis, increases the likelihood of a successful antidepressant treatment response.

CONCLUSION

The goal of antidepressant therapy for patients with depression is to maximize the chance of improvement of symptoms over the course of the therapy. As discussed above, the clinician should consider discussing several specific topics when pharmacologic therapy is initiated. Ensuring that the patient's expectations of antidepressant treatment are realistic in terms of response to therapy, potential adverse reactions to the medication, and the need for follow-up and continuous monitoring is important to minimize the chance of treatment problems. The patient should understand that pharmacologic antidepressant therapy is most effective when coupled with continued efforts by the patient to improve his or her general health and to address personal and family problems.

REFERENCES

Aikens JE, Nease DE Jr, Nau DP, Klinkman MS, Schwenk TL. Adherence to maintenance-phase antidepressant medication as a function of patient beliefs about medication. Ann Fam Med. 2005;3(1):23-30.
Granger AL, Fehnel SE, Hogue SL, Bennett L, Edin HM. An assessment of patient preference and adherence to treatment with Wellbutrin SR: a web-based survey. J Affect Disord. 2006;90(2-3):217-21.
Katon W, Cantrell CR, Sokol MC, Chiao E, Gdovin JM. Impact of antidepressant drug adherence on comorbid medication use and resource utilization. Arch Intern Med. 2005;165(21):2497-503.
Loh A, Leonhart R, Wills CE, Simon D, Harter M. The impact of patient participation on adherence and clinical outcome in primary care of depression. Patient Educ Couns. 2007;65(1):69-78.
Young HN, Bell RA, Epstein RM, Feldman MD, Kravitz RL. Types of information physicians provide when prescribing antidepressants. J Gen Intern Med. 2006;21(11):1172-7.

AUTHOR SPOTLIGHT

William R Yates, MD
Professor of Research
Department of Psychiatry and Family Medicine
University of Oklahoma College of Medicine, Tulsa