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Depression is a relatively common condition among primary care patients, and studies indicate that between 10% and 14% of all patients presenting to their primary care physician (PCP) are clinically depressed. The use of antidepressants in the United States doubled between 1995 and 2002, and likewise, the number of medication choices continues to increase. PCPs today must have a clear understanding of when and how to use antidepressant medications. In the March 15, 2008 issue of the American Family Physician, my colleagues and I published an overview of pharmacologic treatments for adults with depression and provided simple recommendations to improve treatment in the primary care setting.

Be Vigilant With Patients

Major depression is both prevalent and treatable, and pharmacotherapy is likely to benefit many patients. The data show that there is little variation regarding the efficacy of available antidepressants. Specific medications should be chosen after considering patient characteristics, safety profile, and likely adverse effects. All antidepressants may be associated with harmful adverse effects, and some are particularly prone to dangerous drug-drug interactions. When PCPs are managing patients with depression who are taking antidepressants, it’s critical to closely monitor them for adverse effects, suicidality, and effectiveness, especially when initiating therapy and adjusting dosages.

Only about half of all patients treated with antidepressants will respond to treatment in the initial few weeks, and only a third will achieve remission with a single antidepressant. As such, it’s critical for PCPs to be vigilant in diagnosing depression accurately and treating patients aggressively when identified. A misdiagnosis of major depression in a patient who is actually bipolar can lead to use of medications that are inappropriate or ineffective. Before deeming a treatment regimen to be ineffective, depression should be treated with adequate doses of an antidepressant for a minimum of 4 to 8 weeks; a change in therapy is needed if there is no response. If remission is achieved, the antidepressant should be continued for at least 6 months and preferably for an additional 12 months. If patients aren’t responding to treatment, appropriate therapeutic choices may include using a different medication of the same class, a medication from a different class, or augmenting use of the first agent with a second one.

Don't Devalue Side Effects

While the side effect profiles of newer antidepressants have clearly improved, all psychoactive medications have the potential for serious side effects. Common side effects of SSRIs include insomnia, gastrointestinal (GI) disturbances, agitation, and an increased risk of GI bleeding. All antidepressants have the potential for sexual side effects (eg, decreased libido, impotence, and anorgasmia). Actively addressing these issues with patients may improve compliance with therapy. There is little reason to select any initial therapy for depression other than a generic SSRI, although bupropion may have fewer sexual side effects than other drugs, and drugs that affect both serotonin and norepinephrine uptake may have higher early response rates.

Combine Therapeutic Interventions

Patients on antidepressants who also receive psychotherapy are more likely to continue medical therapy. This combination appears to be more effective than medication alone, so PCPs should stress to patients the importance of seeking out additional help. In some cases, cognitive behavioral therapy has been as effective as therapy with antidepressants. Also, all depressed patients should be encouraged to adopt regular exercise programs. Exercise improves symptoms acutely and helps patients maintain a long-term sense of well-being.

Stephen M. Adams, MD, FAAFP has indicated to Physician’s Weekly that he has or has had no financial interests to report.