Why Do You Need to Move Beyond First-Line Therapy for Major Depression?

Primary care clinicians need to move beyond first-line therapy for major depression. While initial treatment is ineffective in about two-thirds of patients, patients who have not responded to such initial treatments can be managed effectively. The severity of depression is as high in primary care as in specialty care settings. The risk of depression is currently elevated because economic hardship, job insecurity, and low socioeconomic status increase the likelihood of depression and treatment resistance. Depression worsens outcomes for medical comorbidities, such as cardiac disease, chronic obstructive pulmonary disease, and diabetes mellitus, and it increases the risk of rehospitalization. When depression is treatment-resistant (generally defined as not responding to 2 courses of treatment of adequate dose and duration), morbidity and mortality are increased, quality of life and function are reduced, and long-term brain changes may occur. Opportunities for change in care are available. Screening for depression in primary care settings with staff-assisted support, adopting the concepts of the patient-centered medical home and stepped care, and using new treatment options such as atypical antipsychotics and other treatment modalities can improve outcomes for these patients. Now is the time to make these moves because new tools, systems, and treatments offer ways to help these patients.

From the Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts.

This article is derived from the planning teleconference series "Looking Past First-Line Therapy for Major Depressive Disorder," which was held in January 2010 and supported by an educational grant from AstraZeneca.

Dr Culpepper is a member of the advisory boards for AstraZeneca, Eli Lilly, Labopharm, Merck, Pfizer, Sanofi, Takeda, and Wyeth and is a former member (resigned) of the Pfizer and Wyeth speakers bureaus.

Corresponding author: Larry Culpepper, MD, MPH, 1 Boston Medical Center Pl, Dowling 5, Boston, MA 02118 ([email protected]).

doi:10.4088/JCP.9104su1c.01

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