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Outpatient Management of Depression 9 - What to Do After the Medication Has Been Selected

Treatment begins with the selection of an antidepressant for the patient. This chapter will review the process to optimally manage the patient after treatment has begun, including:

• Monitoring the initial phase of treatment to ensure that optimal response is achieved
• Educating the patient about the drug treatment so the patient will know what to expect
• Informing the patient about the nature of the illness and the patient's role in treatment to achieve an optimal recovery from the illness. That education must include a discussion of the fact that in many cases clinical depression is a episodic, recurrent illness.

The goal is to have the patient be an active and important part of the treatment team to increase the likelihood of the optimal recovery from the illness.

Initiation and Follow-Up of an Antidepressant Trial

Optimal treatment starts with appropriate patient education about the nature of the illness and the nature of the proposed treatment. That discussion should include:

• The reasons for selecting a specific medication
• When to expect improvement in depressive symptoms
• How that improvement is likely to manifest itself
• What adverse effects the patient may experience
• What to do in the event adverse effects occur.

A script for patient education has been provided in Chapter 4.

The goal of such education is to help the patient be an active participant in his/her treatment. That, in turn, should enhance compliance. The rationale is that patients are more likely to remain on a treatment even if it causes a nuisance adverse effect when they know what to expect and what to do if it occurs. They are also more likely to inform the clinician if they experience an unexpected effect, thus diminishing the likelihood of a serious adverse outcome.

The appropriate interval between the initial visit and the first follow-up visit will typically be either 1 or 2 weeks depending on how well the patient will likely tolerate the medication. The patient should be instructed to either call the clinic or decrease the dose if s/he is having any adverse effects that are more than a nuisance. At the return visit, the practitioner can assess the adequacy of the dosing schedule, determine how well the medication is working, and in the case of a tricyclic antidepressant (TCA), obtain a plasma sample to measure the plasma drug level to guide further dose adjustment (Figure 9.1).¹⁹¹

As discussed in Chapter 8, some antidepressants can cause adverse effects which can be treatment limiting even though not medically serious. In such instances, a closer follow-up may be useful to assess the patient's response, provide reassurance, and take any corrective steps that may be needed (Chapter 11). An example would be the sedative action of mirtazapine which occurs early in treatment, often after the first dose.^151,178 While this sedation is usually not medically serious, it can lead to patient discontinuation. The clinician may choose to deal with that issue by phone if it arises or may wish to schedule a closer follow-up visit to assess the situation.

During interval visits, patient education about the illness and its treatment should continue by:

• Responding to any patient questions
• Clarifying issues as needed
• Providing support and encouragement by addressing any intervening issues (eg, family or employment stresses)
• Assessing the safety, tolerability, and efficacy of the medication trial.

Obviously, the more severe the episode, the closer the follow-up should be. Given the fact that all of the current classes of antidepressants have a delayed onset of clinically significant antidepressant activity, the clinician may want to see the markedly ill patient sooner if there is a possibility that suicidal ideation may emerge between starting the medication and substantial improvement in the depressive episode.

The interval between follow-up is also dependent on whether the practitioner needs to see the patient to:

• Assess response
• Titrate the dose
• Deal with the likelihood of treatment-limiting adverse effects.

The variables that will go into that decision include:

• The personal preferences of the practitioner
• The nature of the patient, including the nature of the depressive illness
• The specific medication selected.

FIGURE 9.1 — Algorithm for Treating Patient With Major Depression

FIGURE 9.2 — Zung Depression Self-Report Rating Scale Name _____________________________ Age__________ Sex_______ Date ________ Please put a check in the box that best reflects how you have mainly felt in the past week for each question.   None Some Mostly Always 1. I feel downhearted, blue, and sad         2. Morning is when I feel the best         3. I have crying spells or feel like it         4. I have trouble sleeping through the night         5. I eat as much as I used to         6. I enjoy looking at, talking to, and being with attractive women/men         7. I notice that I am losing weight         8. I have trouble with constipation         9. My heart beats faster than usual         10. I get tired for no reason         11. My mind is as clear as it used to be         12. I find it easy to do the things I used to do         13. I am restless and can’t keep still         14. I feel hopeful about the future         15. I am more irritable than usual         16. I find it easy to make decisions         17. I feel that I am useful and needed         18. My life is pretty full         19. I feel that others would be better off if I were dead         20. I still enjoy the things I used to do

Even a one- or two-step dose titration schedule can be accomplished without requiring an early return visit. It does require active patient participation and hence proper patient education. For example, a patient who is going to be treated with desipramine can be instructed to start with 50 mg/day for 3 days, advance to 75 mg/day for 3 days, and then to 100 mg/day until s/he returns to see the clinician.

The patient with a first-time episode of clinical depression has a 50:50 chance of having another episode some time in the future.^4,61,98 The likelihood increases if the patient has a strong positive family history for recurrent depressive illness. The patient should be educated about the early warning signs of a recurrent episode to reduce the time between when the patient experiences the onset of an episode and when s/he seeks help. That, in turn, hopefully will reduce the severity and the duration of the episode.

It is useful to explain to the patient with a single depressive episode that there is a good chance s/he will not have another one. In the event another episode occurs, there may be years between the episodes. It should also be emphasized that should future episodes occur, they should be just as responsive to medication as the first one was. There is no reason why the patient should not have a full, productive, and happy life. The goal is to provide a realistic recognition that there is a chance of a recurrence without over-emphasizing the risk and producing the depressive equivalent of a "cardiac cripple."

At the end of a 4- to-6-week trial of the medication, the patient's response can be assessed (Figure 9.1). The response can be divided into three categories:

• Full remission
• Partial response
• No response.

These categories have been defined in Table 5.1. There are several rating scales that have been developed to provide a reliable quantification of the severity of the patient's depressive episode and response to treatment. The one that is most readily adapted to the primary-care setting is the patient self-report questionnaire, the Zung Depression Self-Report Rating Scale (Figure 9.2). This form can be given to the patient to complete before the clinician sees the patient. This approach increases efficiency and reinforces patient education. By completing this form, the patient learns to think about the severity of his/her illness in a more precise and quantifiable way. This education can facilitate the patient's ability to monitor his/her progress.

Duration of Continuation Therapy

If this is a first episode, the patient should remain on the antidepressant for at least 4 months after remission.^4,61,98 This interval is a vulnerable period during which the probability of a relapse is high if the patient does not remain on medication.

During this phase, the patient should be seen generally every 1 to 2 months for follow-up medication checks. During these visits, the practitioner will determine whether the medication continues to be effective in terms of maintaining remission and whether it continues to be well-tolerated and safe. In addition, education about the illness continues by clarifying any questions that the patient may have. This education includes a reiteration of the rationale for maintenance therapy: its purpose and its projected duration.

At the last few visits prior to the termination of continuation therapy, education should shift to the likelihood of a recurrent episode. This training can help the patient be more sensitive to the recurrence of symptoms after the antidepressant medication has been stopped as discussed below.

Maintenance Therapy

Antidepressant medication can be used to prevent future episodes as well as to treat current ones. If the patient has had two previous episodes, there is almost a 90% chance of having future episodes after medication is discontinued.^4,61,98 Even so, the next episode may be years into the future (ie, every 10 years). Indefinite therapy for all such patients seems excessive. Instead, each episode may be treated separately. For patients with seasonal onset to their depressive illness, they may discontinue the medication during the seasons when they are not at risk for a recurrence, but initiate therapy shortly before entering the season at risk.¹⁰³

Clearly, there are some patients for whom the benefits of indefinite antidepressant treatment outweigh the downside. Ideally, the patient should make this decision based on balancing the following factors: the frequency, severity, duration, and recurrent depressive episodes versus problems or inconveniences associated with maintenance antidepressant therapy. Follow-up visits during active prophylactic treatment may be a number of months apart, depending on how long the patient has been on the antidepressant and the nature of his/her depressive illness.