Scientific reference guide: depression in adults

Scientific Reference Guide Depression in Adults
What are the best treatments?
Description of Condition
Depression is a common medical condition with a lifetime prevalence in the United States of 15% among
adults. Symptoms include feelings of sadness, hopelessness, or guilt; diminished interest or pleasure in usual
activities; decreased ability to think or concentrate; and disruptions in sleep or appetite. Clinically important
depression is also known as major depressive disorder, which differs from ordinary sadness. The diagnosis is
based on the presence of characteristic symptoms that are sufficient to interfere with functioning or well-
being, which occur most days for 2 weeks or more. Depression tends to come in episodes, usually lasting for
months, which may resolve spontaneously. However, recurrence is common: there is a 60% chance of remis-
sion after one episode, 70% after two episodes.
Nonprescription Interventions and When to Seek Help
The major treatment options for depression are psychotherapy and antidepressant medications. Other
options include the herbal preparation known as St. John’s wort (Hypericum perforatum) for cases of mild
depression, and electroconvulsive therapy, which has been shown to be relatively safe and effective for cases
of severe, refractory depression. There is some evidence that aerobic exercise reduces the symptoms of depres-
sion and may help to prevent relapse, particularly in elderly persons.
Not all forms of psychotherapy (talk therapy) have been shown to be effective in the treatment of depres-sion. However, cognitive behavioral therapy, problem-solving therapy, and interpersonal psychotherapy areof established benefit and may be considered first-line treatments for outpatients with mild-to-moderatedepression.
Because depression is potentially debilitating and highly treatable, patients with depressed mood or othercharacteristic symptoms lasting 2 weeks or longer should seek professional advice. Patients with severe symp-toms or persistent suicidal thoughts should obtain immediate psychiatric attention.
Categories of Prescription Pharmaceutical Treatments (i.e., Drug Classes)
The major drug classes available for the treatment of depression are the first-generation antidepressants
(e.g., amitriptyline, imipramine, nortriptyline) and the newer, second-generation antidepressants (e.g., flu-
oxetine, sertraline, venlafaxine). Both first- and second-generation drugs treat depression effectively,
although the second-generation agents are associated with fewer side effects and a lower risk of suicide when
taken in overdose. Another group of first-generation antidepressants, monoamine oxidase inhibitors, are
rarely used in general practice because of drug-drug and drug-food interactions. The relative costs of first-
and second-generation antidepressants and other treatments are shown in the Table.
Intraclass Comparisons
■ Overall treatment effects among the second-generation antidepressants appear similar.
Differences, where they exist, are relatively minor: ● Mirtazapine may have a faster onset of action than fluoxetine, paroxetine, and sertraline.
● Based on limited data, venlafaxine may be associated with a higher response rate than
Scientific Reference Guide Depression in Adults
■ Second-generation antidepressants are similar in terms of overall tolerability and safety. Differences in
side-effect profiles are relatively minor but may be clinically important in some patients: ● Bupropion and nefazodone may be associated with fewer sexual side effects as compared with other sec-
ond-generation antidepressants. However, nefazodone is no longer a first-line agent owing to concernsabout liver toxicity (approximately one case of severe liver failure or death per 250,000 patient-yearsof exposure).
● Compared with other second-generation antidepressants, venlafaxine may cause more nausea and be
associated with an increased risk of seizures in overdose.
● Mirtazapine and paroxetine may lead to greater weight gain as compared with bupropion, fluoxetine,
■ The likelihood that sudden cessation of antidepressant therapy will lead to withdrawal symptoms (includ-
ing dizziness, nausea, paresthesias, and headache) is inversely related to the half-life of the drug.
Paroxetine is more often associated with withdrawal symptoms than are sertraline and fluoxetine.
■ In general, second-generation antidepressants appear to have similar efficacy and side effects in the elderly
■ The use of antidepressants in children and adolescents is controversial. A “black box” warning cautions
that in short-term studies antidepressants increased the risk of suicidal thinking and behavior amongpatients in this age group.
■ Ethnic differences in the effectiveness and safety of second-generation antidepressants have not been ade-
■ First- and second-generation antidepressants taken during pregnancy have not been associated with an
increased risk of major congenital malformation. However, information on the long-term neurobehav-ioral effects of these medications is limited, and withdrawal syndromes among infants have beenobserved. Based on pharmacokinetic studies and clinical follow-up, nortriptyline, paroxetine, and sertra-line may be the preferred choices in women who breast-feed. Interclass Comparisons
■ Psychotherapy (especially cognitive behavioral therapy, problem-solving therapy, and interpersonal
psychotherapy) and antidepressant medications are both effective first-line treatments for patientswith mild-moderate depression.
■ Cognitive behavioral therapy and second-generation antidepressants are equally effective in the short-
term treatment of postpartum depression.
■ The combination of psychotherapy plus an antidepressant medication is more effective than either alone
■ Neither pharmacotherapy nor psychotherapy act immediately to reduce the symptoms of depression.
Both take several weeks or more for maximal effect.
Scientific Reference Guide Depression in Adults
Conclusions
■ Clinically important depression is common and treatable.
■ Second-generation antidepressants and certain forms of psychotherapy are safe and effective treatments
for adults with mild-moderate depression.
■ Prolonged treatment (6 months or more) is necessary to reduce the risk of relapse.
Methods Note
This scientific reference guide is a product of the Prescription Drug Information Project, a collaborative ven-
ture between the University of California and the California HealthCare Foundation. This summary is based
on a report on the effectiveness and safety of second-generation antidepressants performed by the Drug
Effectiveness Review Project (DERP). The DERP report is based on a rigorous method of systematic litera-
ture reviews, ensuring inclusion of relevant studies of high quality. Another team of researchers, at the
University of California (UC), Davis, prepared a supplementary report on other drug and nondrug treatments
for depression. Both reports (DERP and UC Davis) were reviewed by two outside experts and subse-
quently evaluated by a panel of highly regarded physicians and pharmacists from the University of California.
These reports are available at www.chcf.org.
Scientific Reference Guide Depression in Adults
Relative Costs of First- and Second Generation Antidepressants and Other Treatments
Drug Name (generic)
Low ($1 - 50)
Medium ($51 - 100)
High ($101 +)
First Generation
Second Generation
+ Approximate Cost Per One Month Supply.
MAOI, monoamine oxidase inhibitor; SNRI, selective norepinephrine reuptake inhibitor; SSRI, selectiveserotonin reuptake inhibitor.
Prices are from drugstore.com (February 2005).
Scientific Reference Guide Depression in Adults
Relative Costs of First- and Second Generation Antidepressants and Other Treatments (cont.)
Drug Name (generic)
Low ($1 - 50)
Medium ($51 - 100)
High ($101 +)
Second Generation (cont.)
Complementary/Herbal Therapy
+ Approximate Cost Per One Month Supply.
MAOI, monoamine oxidase inhibitor; SNRI, selective norepinephrine reuptake inhibitor; SSRI, selectiveserotonin reuptake inhibitor.
Prices are from drugstore.com (February 2005).

Source: http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/D/PDF%20DepressionSRG.pdf