COMMENTARY

A Guide to Treating Depression

Matt A. Goldenberg, DO

Disclosures

December 08, 2014

In This Article

Psychopharmacology

Some patients come to my office looking for "a pill" to help. Others come and start off by saying, "I don't believe in medication." Regardless of their preconceived beliefs about medication, I always educate my patients so that they can make a balanced decision about the risks, benefits, and alternatives to every treatment option. I work with them to decide whether a medication is right for them. It is especially important for us to be on the same page, because the patient makes the ultimate decision whether or not to take a medication after they leave my office.

Several medications have been proven to be of benefit in the treatment of depression. They generally fall into a specific class of medication and include selective serotonin reuptake inhibitors, serotonin/norepinephrine reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors. Other medications that do not fit as nicely into a specific class have also been proven to be useful in the treatment of depression. When assessing which medication may be right for a patient, it is always important to consider their history of medication successes and failures.

When taking a patient's medication history, it is important to ask how the medications were administered and at what doses. For example, a patient may report that a medication made them "too tired." Therefore, you should inquire about what time of day they were taking the medication, to rule out whether they were erroneously taking a potentially sedating medication in the morning. In this case, it could be worthwhile to prescribe a medication again, with the proper administration time. If you do not collect the full medication history, you may miss opportunities to utilize medications that have the potential to be very beneficial.

In another example, a patient may report that a medication "never worked." You should discuss what dose the patient was previously prescribed and also the duration of treatment. You may find that the patient was taking a subtherapeutic dose or was given only a limited trial. I generally do not consider a medication trial a failure until the patient has had 6-8 weeks on a therapeutic dose without the desired effect. Prescribing a medication that a patient reports has "never worked" may turn out to be beneficial with proper dosing and adequate duration of treatment.

If there are medications that a patient reports they were unable to tolerate, or that did not work well in the past (with a full trial at therapeutic dosing), I tend to avoid those. In contrast, medications that worked well in the past are more likely to help again now.

After considering medication history, I then look at the patient's specific symptoms of depression. These symptoms serve as our targets for treatment and align better with some medications and worse with others. I target the most severe and urgent symptoms, and also comorbid symptoms, such as anxiety, thought distortions, obsessions, and compulsions.

I work with my patients to pick a medication or combination of medications that best suits their personal and current needs. My goal is also to use the fewest number of medications and the lowest effective doses possible. Having a psychiatrist manage medication is important because medications affect each patient uniquely.

At each visit, I evaluate the need to adjust the prescribed medications through changes in dosing (up or down), or augmenting them with additional medications, to achieve optimal outcomes. It is important to understand that the medications used in the treatment of depression can take a week or two to take effect. The medications often do not reach their maximum effectiveness for 6-8 weeks after initiation and subsequent dose changes. Therefore, follow-up visits should be scheduled around these factors to optimize your patient's return to health. For example, if you start an antidepressant medication without follow-up in 2-4 weeks, you will miss opportunities to make dose changes to achieve maximum efficacy with minimal adverse effects.

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