It is especially important for the patient to have the opportunity to work out her feelings about having a psychiatric disorder, understand how it has affected her life, and feel comfortable taking medication or undergoing psychotherapy (115). Patients often attribute depression to weakness, laziness, or immorality, and they often confuse antidepressants with stimulants, tranquilizers, and other psychoactive drugs. Although written materials cannot substitute entirely for verbal instruction, it is useful to provide the patient with written material about depression so that she can review it at her leisure and with her family and friends if they have difficulty understanding her condition. There is widespread difficulty understanding written information, especially about medicine. Many or most antidepressant prescriptions are either not filled or not taken as prescribed (116).
Depression in one individual has a powerful effect on other members of the family, particularly children. This can be a motivating factor for patients who are reluctant to accept treatment.
The types and characteristics of antidepressants are presented in Table 12.3. All antidepressants have comparable therapeutic efficacy, and all require up to 2 to 4 weeks to take full effect.
It is not yet possible to identify those patients who will respond best to certain medications, but there is early evidence that depression may be related to specific neurotransmitters and respond differentially to medications affecting a given neurotransmitter. The response to treatment may differ with gender, but the data are not sufficient to drive clinical decisions (117).
It is sensible to use a more activating agent (ﬂuoxetine) in a lethargic patient and a more sedating agent (paroxetine) in an agitated patient (118). Nonetheless, responses vary on an individual basis, even within the same class of medications. The choice of antidepressant is based on side effects, dosage, cost, and the physician’s clinical experience (Table 12.4). Patients tend to respond to medications that worked for them in the past and to those that worked for depressed family members. Many patients require successive trials of two or more antidepressants before the one that is effective for them is identified. It is essential to continue active management through the usual duration of a depressive episode—9 to 12 months for major depression,
Table 12.3 Pharmacology of Antidepressant Medications
MAO, monoamine oxidase; bid, two times a day. aHalf-lives are affected by age, gender, race, concurrent medications, and length of drug exposure. bIncludes both ﬂuoxetine and norﬂuoxetine. cBy extrapolation from ﬂuoxetine data. dMAO inhibition lasts longer (7 days) than drug half-life. eIncluding pseudoephedrine, phenylephrine, phenylpropanolamine, epinephrine, norepinephrine, and others. Modified From Depression Guideline Panel. Depression in primary care: detection, diagnosis, and treatment. Quick reference guide for clinicians, no. 5. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1993:15; AHCPR pub. no. 93-0552, with permission.
Table 12.4 Side-Effect Profiles of Antidepressant Medications aNumerals indicate the likelihood of side effect occurring ranging from 0 (for absent or rare) to 4+ (for relatively common). bDry mouth, blurred vision, urinary hesitancy, constipation. From Depression Guideline Panel. Depression in primary care: detection, diagnosis, and treatment. Quick reference guide for clinicians, no. 5. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1993:14;AHCPR pub. no. 93-0553, with permission.
until the patient has responded sufficiently that she has returned to her previous level of mood and function. If the patient does not recover completely, she should be referred to a psychiatrist (118).