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ACP Guideline Finds No Substantial Differences Among “Second-Generation” Antidepressants

New guideline looks at effectiveness of drugs used to treat depressive disorders

This article also is the subject of an American College of Physicians video news story.

Philadelphia, November 18, 2008 – Second generation treatments for depression are all equally effective according to a new clinical practice guideline from the American College of Physicians (ACP). The guideline is published today in Annals of Internal Medicine, ACP's flagship journal.

"The studies we analyzed show that second-generation drugs have different adverse effects but are equally effective for treating depression," said Amir Qaseem, MD, PhD, MHA, senior medical associate in ACP's Clinical Programs and Quality of Care Department and the lead author of the guideline. "ACP recommends that physicians make treatment decisions based on side effects, cost, and patient preferences, and make necessary changes in therapy if the response is not sufficient after six to eight weeks. Doctors should also assess patient status and adverse effects on a regular basis starting within one to two weeks of starting the treatment."

To develop the guideline, ACP reviewed more than more than 200 published studies about the benefits and harms of second-generation drugs -- bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazadone, and venlafaxine -- used to treat depression.

The ACP guideline, "Using Second-Generation Antidepressants to Treat Depressive Disorders," contains four recommendations:

- When clinicians choose pharmacologic therapy to treat patients with acute major depression, they should select second-generation antidepressants on the basis of adverse effect profiles, cost, and patient preferences.

Adverse effects can range from mild, such as constipation or diarrhea, to severe, such as suicidal thoughts.

- Clinicians should assess patient status, therapeutic response, and adverse effects of antidepressant therapy on a regular basis beginning within one to two weeks of initiation of therapy.

The U.S. Food and Drug Administration advises that all patients receiving antidepressants should be closely monitored on a regular basis for increases in suicidal thoughts and behaviors. The risk for suicide attempts is greater during the first one to two months of treatment.

- Clinicians should modify treatment if the patient does not have an adequate response to drug therapy within six to eight weeks of the initiation of therapy for major depressive disorder.

- Clinicians should continue treatment for four to nine months after a satisfactory response in patients with a first episode of major depressive disorder. For patients who have had two or more episodes of depression, an even longer duration of therapy may be beneficial to prevent relapse or recurrence.

Depressive disorders will affect about 16 percent of U.S. adults in their lifetime. The economic burden of depressive disorders is estimated to be about $83 billion.

Depression is a disorder that causes sadness that interferes with daily life. It 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. Any stressful situation, such as a financial or economic crisis, may trigger a depressive episode. Common symptoms of depression are lack of energy and loss of interest in things previously enjoyed.

"People with depression may not realize that their feelings could be due to a medical condition," said Dr. Qaseem. "A loss of interest or pleasure from most daily activities, decreased ability to think or concentrate, or fluctuation in weight or sleeping patterns could be signs of depression. If people experience these symptoms for more than a few weeks, they should talk to their doctor."

Options to manage depression such include drug therapy, psychotherapy, and cognitive behavioral therapy. If drug therapy is warranted to treat the depression, second-generation drugs are often used because they are effective and have fewer side effects than older, "first-generation" drugs.

Depression is more prevalent during the late fall or winter months when a reduced amount of natural sunlight can trigger seasonal affective disorder, or SAD. During these months some people may also experience deep sadness, dread, or loneliness due to the approaching holidays.

About Annals of Internal Medicine and the American College of Physicians

Annals of Internal Medicine is one of the five most widely cited peer-reviewed medical journals in the world. The journal has been published for 81 years and accepts only 7 percent of the original research studies submitted for publication. Annals of Internal Medicine is published by the American College of Physicians, the largest medical specialty organization and the second-largest physician group in the United States.

ACP members include 126,000 internal medicine physicians (internists), related subspecialists, and medical students. Internists specialize in the prevention, detection, and treatment of illness in adults.

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