John E. Sutherland, MD Northeast Iowa Family Practice Residency Program,Waterloo and University of Iowa College of Medicine, Iowa City JSutherl@neimef.org
Steven J. Sutherland, MD Human Development Center, University of Minnesota-Duluth School of Medicine, Duluth
James D. Hoehns, PharmD Northeast Iowa Family Practice Residency Program, Waterloo, and University of Iowa College of Pharmacy, Iowa City
The process of drug selection just described can avoid treatment-threatening side effects, enable patient adherence to treatment, and maximize the potential for therapeutic response. However, the model can become disorienting for the clinician and the patient if 1 or 2 initial selections for treatment do not succeed. A useful synergy may be achieved by adapting the intuitive model to an algorithmic model—the Texas Medication Algorithm Project (TMAP). TMAP is an evolving model that reflects ongoing clinical research in the treatment of depression.27
Developed in 1995 from a review of existing antidepressant research and several consensus conferences, the TMAP (continually updated with new research findings) has developed algorithms for treatment of schizophrenia and bipolar disorder in addition to major depression. At each stage in the depression algorithm, treatment plans similar in efficacy and safety are grouped together, and the clinician is given a limited number of options. The later stages in the algorithm are more complex, admittedly with a greater potential for medical complications (Figure).51
The algorithm represents a tentative foundation for a sequenced medication plan. Research pertaining to the selection of antidepressant medicationis underway, sponsored by the National Institute of Mental Health. Unlike most antide-pressant trials, this study includes subjects with significant concomitant medical illnesses.
FIGURE Treatment of chronic major depression*
When to refer
Patients requiring referral to a psychiatrist include those with suicidal ideation or severe depression, aggressive ideation, bipolar disorder, atypical depression, psychotic depression, substance abuse, or treatment resistance.52 Referral to a licensed counselor should be offered to most patients with depression, with or without psychiatric involvement, though many factors (eg, patient motivation, capacity for insight, patient perceptions of therapist) will affect follow-through and outcome.
Maintenance therapy
Once full remission has been achieved, 6 to 12 months of continued pharmacotherapy at the same dose is recommended, as it decreases the risk of relapse by 70%.5,21,26 More than half of patients will have a recurrence of depression in their lifetime, and they should be advised about this risk.1
A second episode of major depression confers an 80% chance of additional recurrences, and patients should therefore be maintained on medication for 1 to 2 years.
A third episode requires indefinite maintenance treatment because of a 90% recurrence rate.3,26
Follow-up visits after remission can be tapered gradually to once every 3 months. Discontinuation of therapy should be done gradually to minimize withdrawal reactions; it also necessitates follow-up visits or phone calls.
* For a review of screening for depression, see Nease DE, Malouin JM. Depression screening: A practical strategy. J Fam Pract 2003; 52(2):118–126.
