Clinical depression is a major problem in the United States, affecting an estimated 5% to 10% of all adults. Costs for medical
care and lost productivity related to depression are estimated at more than $40 billion per year.
Some Drugs for Depression
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Antidepressant drugs yield remissions in about 30% of adults with major depression and produce some response in about 50%
to 60% of cases. They may take two to four weeks to show an improvement, and six to eight weeks to achieve substantial benefit.
Selective serotonin reuptake inhibitors (SSRIs) are the first choice for treatment for depression in both adults and children.
There is no good evidence that any one SSRI is more effective than any other. "Jitteriness and insomnia early in treatment
with SSRIs can be minimized by starting with low doses, possibly even lower than those recommended by the manufacturer for
initial treatment," says Mark Abramowicz, MD, editor of The Medical Letter on Drugs and Therapeutics, a non-profit newsletter that critically appraises drugs.
Effexor (venlafaxine) is a serotonin-norepinephrine reuptake inhibitor (SNRI) that may be more effective than an SSRI for
some patients with depression. "For the majority of patients, SSRIs appear to be just as effective," says Dr. Abramowicz.
"Cymbalta [duloxetine], an SNRI, also approved for treatment of neuropathic pain, is marketed particularly for treatment of
depression in patients who are experiencing significant pain." CONTROVERSIAL BLACK BOX WARNINGS
Recent years have seen a great deal of concern about antidepressants possibly increasing the risk of suicidal behavior, particularly
when prescribed for young people. In 2004, FDA began requiring drug companies to put black-box warnings on antidepressant
labels, advising doctors and patients about potential increased risk in children and adolescents.
This warning has been highly controversial, and there's evidence it has led to a decline in antidepressant use among young
people. In 2005, the American Medical Assn. adopted a resolution saying that antidepressants haven't been shown to increase
the risk of completed suicide in children and adolescents, and that children should not be denied possibly life-saving medication.
"Medical Letter consultants believe that these drugs are much more likely to prevent suicide than to cause it. All depressed
children, adolescents and adults, whether they are treated with drugs or not, should be monitored for suicidal ideation or
behavior," says Dr. Abramowicz.
A recent meta-analysis of 27 studies on antidepressant use in adolescents found that the risk of suicidal thinking and behavior
is lower than previously thought. This study, published in JAMA in April, found that for every 100 patients treated with antidepressant medications, less than one had an increased risk
of suicidal thoughts. None of the studies found any completed suicides.
MANAGED CARE REACHES OUT
In addition to medication, psychotherapy, education and social support are essential parts of treatment for depression. "Our
experience has shown that proactive assessment and early intervention combined with structured care coordination services
enables optimal treatment outcome for our members," says Hyong Un, MD, national medical director for Aetna Behavioral Health.
With 15.7 million members covered by all of its medical plans, Aetna has developed two disease management programs for depression.
The medical psychiatric program focuses on members who have both medical and behavioral health issues, using care managers
to coordinate care between the two disciplines. The depression disease management program uses care managers to help members
with depression access providers and use their pharmacy benefits effectively. Both programs rely on phone calls between patients
and behavioral health clinicians, including nurses, licensed social workers, and psychologists. "We've found that members
enrolled in these programs were more likely to follow up on treatment, report to work and meet job requirements consistently,"
says Dr. Un.
