Individualizing drug therapy for adults with major depressive disorder

Managing patients with depressive disorders constitutes a significant portion of the typical family physician’s practice. A serial cross-sectional study in Health Affairs estimated that the percentage of U.S. adult primary care visits that addressed mental health concerns rose from 10.7% in 2006 to 15.9% by 2018. Previous AFP Community Blog posts have discussed the primary care evidence base for psychologic and pharmacologic treatments and screening and treatment guidelines from the U.S. Preventive Services Task Force and the American College of Physicians (ACP). In the February issue, Dr. Heather Kovich and colleagues provided an update on pharmacologic treatment and tapering strategies to minimize the risk of discontinuation syndrome. When initiating medication, the authors recommend using shared decision-making, considering factors such as “prior treatment and response, comorbidities, costs, and risk of adverse effects.”

An accompanying editorial by Drs. Andrew Buelt and John McQuaid compared the three major U.S. clinical guidelines for major depressive disorder from the ACP, the American Psychological Association (APA), and the U.S. Department of Veterans Affairs and Department of Defense (VA/DoD). (The ACP released an update to its 2016 guideline while the article and editorial were in press.) All of the guidelines recommend initial treatment with evidence-based psychotherapy or pharmacotherapy. Pharmacogenetic tests such as GeneSight Psychotropic “[have] not been shown to improve patient-oriented outcomes and [are] not recommended to assist in drug choice.” Most patients will not experience additional benefit from combining psychotherapy and pharmacotherapy; however, the VA/DoD suggests that this combination is appropriate for patients with severe, persistent (more than two years), or recurrent (two or more episodes) depression.

A Canadian group recently developed a visual evidence-informed decision support tool based on a literature review and the Canadian Network for Mood and Anxiety Treatments depression treatment guidelines. The tool consists of two Figures that guide primary care clinicians in antidepressant selection based on specifiers (sleep disturbance, cognitive dysfunction, anxious distress, somatic symptoms), comorbid conditions, adverse effects, drug interactions, and administration. Physicians using this tool should note that the costs of antidepressants in Canada are considerably lower than those in the U.S., even for Medicare beneficiaries. Another helpful decision tool for antidepressants and other psychiatric drugs is the Waco Guide to Psychopharmacology in Primary Care, which is available as a downloadable app for Apple users.

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This post first appeared on the AFP Community Blog.