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The active management of depression - Clinical Update

Journal of Family Practice, Sept, 2002 by Larry Culpepper

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When indicated, treatment should be discontinued by tapering the dose over several weeks to months, depending on the duration and severity of past episodes. Patients should be educated to be alert for recurrence. They should also be monitored for recurrence and restarted on full-dose therapy if this occurs. If patients stop therapy abruptly, the likelihood of withdrawal symptoms (agitation, irritability, dizziness, ataxia, nausea, paresthesias, sleep disturbances) is highly related to the half-life of the SSRI. (39) For paroxetine, which has the shortest half-life, withdrawal is frequent; the extended release preparation does not decrease the likelihood of withdrawal. Withdrawal symptoms are infrequent (< 2%) for sertraline, citalopram, and escitalopram, and they do not occur with fluoxetine.

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Duration of Treatment

A major challenge in family practice is maintaining patient adherence to treatment for the recommended interval to prevent relapse and to avoid recurrence in those with a history of prior episodes. In one study, 25% to 33% of primary care patients stopped depression therapy within 1 month and over 40% within 3 months. Additionally, 62% failed to inform their physicians. (54) Depression also adversely affects compliance with treatment of comorbid medical conditions; in one meta-analysis, depression increased noncompliance 3-fold. (54)

For the first lifetime episode, the recommended duration of treatment is 6 to 9 months (4 to 6 months after recovery). (55) Longer therapy is appropriate for those with comorbid anxiety disorders, severe initial symptoms, difficulty in attaining therapeutic response, deficient social support, or a history of substance abuse, as well as for older adults. For patients with 3 or more previous episodes, long-term maintenance therapy is recommended. (55) For those with even one past episode, extended maintenance therapy might be beneficial. Maintenance therapy should be at the full dose required to attain initial response. In one study, only about 20% to 30% (depending on the treatment) experienced recurrence over 3 years if maintained at full dose, compared with 70% maintained at half the initial treatment dose, and 78% of those receiving placebo. (56) For women who have previously suffered from postpartum depression, postpartum prophylaxis can be very effective. In one randomized trial, 62.5% of women on placebo experienced recurrence compared with only 6.7% of those receiving prophylaxis. (57)

Practice Strategies to Improve Care

A number of primary care investigators have demonstrated the value of practice management and quality improvement techniques to increase the portion of patients who achieve and maintain response to depression therapy. These studies share an approach of "active management" to promote adherence to treatment guidelines. (58-63) For instance, Simon and colleagues demonstrated the value of initial and monthly phone contact. (64)

Active management techniques include the following:

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The active management of depression - Clinical Update

Journal of Family Practice, Sept, 2002 by Larry Culpepper

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