Use of Drugs to Treat Depression: Guidelines from the American College of Physicians

Summaries for Patients are a service provided by Annals to help patients better understand the complicated and often mystifying language of modern medicine.

Summaries for Patients are presented for informational purposes only. These summaries are not a substitute for advice from your own medical provider. If you have questions about this material, or need medical advice about your own health or situation, please contact your physician. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the American College of Physicians.

The summary below is from the full reports titled "Using Second-Generation Antidepressants to Treat Depressive Disorders: A Clinical Practice Guideline from the American College of Physicians" and "Comparative Benefits and Harms of Second-Generation Antidepressants: Background Paper for the American College of Physicians." They are in the 18 November 2008 issue of Annals of Internal Medicine (volume 149, pages 725-733 and pages 734-750). The first report was written by A. Qaseem, V. Snow, T.D. Denberg, M.A. Forciea, and D.K. Owens, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians; the second report was written by G. Gartlehner, B.N. Gaynes, R.A. Hansen, P. Thieda, A. DeVeaugh-Geiss, E.E. Krebs, C.G. Moore, L. Morgan, and K.N. Lohr.

Who developed these guidelines?

The American College of Physicians (ACP) developed these recommendations. Members of the ACP are internists, specialists in the care of adults.

What is the problem and what is known about it so far?

Depression causes sadness that interferes with daily life. Depression is a medical condition, not a normal reaction to such life situations as the death of a loved one or the loss of a job. About 1 out of every 5 people has depression at some time in his or her life. Common depression symptoms are lack of energy and loss of interest in things previously enjoyed. Often, people with depression do not realize that their feelings are due to a medical condition and do not seek medical care. Many depressed people need treatment with counseling or drugs.

Several types of drugs are available to treat depression. Newer, "second-generation" drugs are often used to treat depression because they are effective and have fewer side effects than older, "first-generation" drugs. Nonetheless, antidepressant drug therapy may relieve some but not all symptoms and may cause troublesome adverse effects. If an antidepressant drug does not work well, doctors sometimes switch to another drug or add a second drug.

How did the ACP develop these recommendations?

The authors reviewed published studies about the benefits and harms of drugs used to treat depression. The reviewers focused on second-generation antidepressants—bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazadone, and venlafaxine (generic names).

What did the authors find?

On the basis of more than 200 studies, no substantial differences in efficacy or effectiveness for the treatment of depression were found among second-generation depression drugs. Specific drugs differed in the frequency of specific side effects. Studies suggested that patients with a first episode of depression should take the drugs for 4 to 9 months to lower the chances of the depression coming back. Patients with 2 or more episodes of depression may benefit from longer treatment.

What does the ACP suggest that patients and doctors do?

When drugs are used to treat depression, doctors and patients should select a second-generation antidepressant on the basis of side effect profiles, cost, and patient preferences.

When drugs are used to treat depression, doctors should follow patients on a regular basis to check on response to treatment and side effects. This follow-up should begin within 1 to 2 weeks after the patient first receives the drug.

If a patient's depression does not improve within 6 to 8 weeks of starting drug treatment, doctors should either increase the dose or switch to a different drug.

Patients with a first episode of depression that goes away with drug treatment should continue the drug for another 4 to 9 months to decrease the chance that the depression will come back. Patients who have had 2 or more episodes of depression may need to continue the drug for more than 9 months.

What are the cautions related to these recommendations?

These recommendations may change as new research is done.