"Pharmacologic Management of Adult Depression" (My Synopsis)

My Synopsis or AFP's
Pharmacologic Management of Adult Depression
STEPHEN M. ADAMS, MD; KARL E. MILLER, MD; and ROBERT G. ZYLSTRA, EdD, LCSW University of Tennessee College of Medicine, Chattanooga, Tennesse
Am Fam Physician. 2008 Mar 15;77(6):785-792.
http://www.aafp.org/afp/2008/0315/p785.pdf

     The incidence of depression is over 10% in all patients presenting in the outpatient setting. Only about 50% of depressed patients will respond to treatment of a single antidepressant. Only about 1/3 of these patients will have remission after 12 weeks. In patients who respond to treatment, it may take at least 8 weeks for a response to occur.
     TCAs are antidepressants medication that block norepinephrine and serotonin reuptake. Examples include amitriptyline, imipramine, and nortriptyline. side effects include weight gain, sedation, constipation, dry mouth, orthostatic hypotension and reflex tachycardia. TCAs are metabolized by the P450 system. An overdose from TCAs can be fatal but may only just cause respiratory depression, arrhythmias, hallucination and hypertension.
     SSRIs, including citalopram, escitalopram, fluoxetine, paroxetine, and sertraline, inhibit serotonin reuptake presynaptically. SNRIs, including duloxetine and venlafaxine, inhibit serotonin and norepinephrine reuptake presynaptically. Side effects from these drugs include agitation, insomnia, GI problems, and sexual disfunction. They are also metabolized by the P450 system. Medications that are metabolized by the P450 system slow the metabolism or other medications using the P450 system, thus SSRIs and TCA don't play well together.
     Bupropion inhibits presynaptic reuptake of norepinephrine and dopamine. Mirtazapine blocks 5HT2A and 5HT2C serotonin receptors. These two can interact with TCAs and SSRIs. MAOIs are not often used due to their poor side effect profile when mixed with certain foods.
     Different antidepressants do different things (duh). Amitriptyline is more effective but has more side effects. Fluoxetine is less effective than other meds. Mirtazapine has a faster onset of action, but can affect sleep and increase weight gain. Bupropion increases weight loss and does not cause sexual side effects. Of the SSRIs paroxetine causes the most weight gain, fluoxetine causes the least.
     Whichever treatment is used, the patient needs to give the medication 1-2 months to let it take effect before changing it or adding something else. If the medication does work, its need to be continued for 6 months to a year to prevent relapse. SSRIs and SNRIs need to be tapered slowly to avoid "discontinuation syndrome".
    Patients who received psychotherapy, CBT or regular contact from their doctor ( in the form of office visits or phone calls) have a higher rate of compliance. Adding benzodiazepines to antidepressants help compliance.  Patients who receive a combination of psychotherapy and medication get more benefit than only one.