Achieving the best outcome in treatment of depression

Journal of Family Practice, March, 2003 by John E. Sutherland, Steven J. Sutherland, James D. Hoehns

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The algorithm represents a tentative foundation for a sequenced medication plan. Research pertaining to the selection of antidepressant medication is underway, sponsored by the National Institute of Mental Health. Unlike most antidepressant trials, this study includes subjects with significant concomitant medical illnesses.

When to refer

Patients requiring referral to a psychiatrist include those with suicidal ideation or severe depression, aggressive ideation, bipolar disorder, atypical depression, psychotic depression, substance abuse, or treatment resistance. (52) Referral to a licensed counselor should be offered to most patients with depression, with or without psychiatric involvement, though many factors (eg, patient motivation, capacity for insight, patient perceptions of therapist) will affect follow-through and outcome.

* MAINTENANCE THERAPY

Once full remission has been achieved, 6 to 12 months of continued pharmacotherapy at the same dose is recommended, as it decreases the risk of relapse by 70%. (5,21,26) More than half of patients will have a recurrence of depression in their lifetime, and they should be advised about this risk. (1)

A second episode of major depression confers an 80% chance of additional recurrences, and patients should therefore be maintained on medication for 1 to 2 years.

A third episode requires indefinite maintenance treatment because of a 90% recurrence rate. (3,26)

Follow-up visits after remission can be tapered gradually to once every 3 months. Discontinuation of therapy should be done gradually to minimize withdrawal reactions; it also necessitates follow-up visits or phone calls.

TABLE

Comparative dosages and costs of antidepressant drugs

                                   Initial target   Maximum effective
Agents                             dose             dose

Selective serotonin reuptake inhibitors

Citalopram (Celexa)                 20 mg qd         60 mg qd
Escitalopram (Lexapro)              10 mg qd         20 mg qd
Fluoxetine (Prozac)                 20 mg qd         80 mg qd
Fluoxetine (generic)                20 mg qd         80 mg qd
Fluoxetine (Prozac Weekly)          90 mg qwk
Fluvoxamine (Luvox)                 50 mg qd        150 mg bid
Paroxetine (Paxil)                  20 mg qd         60 mg qd
Paroxetine (Paxil CR)               25 mg qd         75 mg qd
Sertraline (Zoloft)                 50 mg qd        200 mg qd

Tricyclic antidepressants

Amitriptyline (Elavil,             100 mg qhs       300 mg qhs
Endep, Vanatrip)
Desipramine (Norpramin)            100 mg qhs       200 mg qhs
Doxepin (Adapin, Sinequan)         100 mg qhs       300 mg qhs
Imipramine (Tofranil)              100 mg qhs       300 mg qhs
Nortriptyline (Aventil, Pamelor)    75 mg qhs       150 mg qhs

Others

Bupropion (Wellbutrin)             100 mg tid       150 mg tid
Bupropion (generic)                100 mg tid       150 mg tid
Bupropion (Wellbutrin SR)          150 mg bid       200 mg bid
Mirtazapine (Remeron)               30 mg qhs        45 mg qhs
Nefazodone (Serzone)               100 mg bid       300 mg bid
Trazodone (Desyrel)                100 mg bid       300 mg bid
Venlafaxine (Effexor)              37.5mg bid       150 mg tid
Venlafaxine (Effexor XL)            75 mg qd        225 mg qd
Lithium (Eskalith, Lithobid,       300 mg bid       600 mg bid
Lithonate, Lithotabs)

                                   Monthly cost of
Agents                             initial target dose *

Selective serotonin reuptake inhibitors

Citalopram (Celexa)                $61.58
Escitalopram (Lexapro)             $65.28
Fluoxetine (Prozac)                $81.78
Fluoxetine (generic)               $61.80
Fluoxetine (Prozac Weekly)         $71.04
Fluvoxamine (Luvox)                $59.70
Paroxetine (Paxil)                 $70.98
Paroxetine (Paxil CR)              $75.86
Sertraline (Zoloft)                $65.24

Tricyclic antidepressants

Amitriptyline (Elavil,             $ 7.99
Endep, Vanatrip)
Desipramine (Norpramin)            $18.54
Doxepin (Adapin, Sinequan)         $ 8.12
Imipramine (Tofranil)              $31.96
Nortriptyline (Aventil, Pamelor)   $ 8.71

Others

Bupropion (Wellbutrin)             $92.33
Bupropion (generic)                $64.62
Bupropion (Wellbutrin SR)          $87.09
Mirtazapine (Remeron)              $80.79
Nefazodone (Serzone)               $74.94
Trazodone (Desyrel)                $15.98
Venlafaxine (Effexor)              $74.39
Venlafaxine (Effexor XL)           $66.25
Lithium (Eskalith, Lithobid,       $13.70
Lithonate, Lithotabs)

* Costs from www.drugstore.com, November 2002.