Best Practices for Prescribing Antidepressants

More than 16 million adults—nearly 7 percent of the population—have major depression each year. Depression is a leading cause of disability worldwide, with an annual economic burden of more than $210 billion dollars. Depression presents a major public health crisis, yet depression stigma is a major deterrent to seeking help. Moreover, many people with depression who seek help do not get evidence-based care. This can intensify the depression, particularly among people experiencing low motivation and hopelessness.

Most people with depression must try more than one medication before they get relief. Many must combine several medications. Clinicians need to be upfront that depression is a complex illness and that treatment requires some experimentation. False promises about a simple and immediate cure only add to patient frustration. When managing patients struggling with major depressive order, here are some key tips to follow:

Start With One Medication at a Low Dose

Many patients with depression have co-occurring conditions, such as sleep or anxiety disorders. To ensure optimal benefits to the patient and closely track side effects, avoid starting with more than one medication at a time. Instead, start with the lowest dose that is likely to be efficacious and monitor for 2-4 weeks. If there are no serious side effects, and the drug appears to be working well, it is safe to evaluate adding another medication.

Discuss Side Effects

Side effects are the primary reason why people quit taking antidepressants. Frustratingly, many antidepressant side effects can compound the effects of depression. Low libido can undermine relationships, weight gain can affect self-esteem, and insomnia can intensify the exhaustion and grogginess many depressed people feel.

It is important to be honest and open with patients about potential side effects. Discuss which side effects they are most concerned about with them, and make prescribing decisions with this in mind. For a person concerned about the effect of an antidepressant on their sex drive, for example, a drug such as Wellbutrin that is less likely to hinder libido may be appropriate.

Education about the side effects of antidepressants is also critical. For most patients, side effects appear before the drug begins working and peak between 2-4 weeks before finally leveling off. Reassure patients that any side effects may soon dissipate and that the relief the drugs offer typically appears shortly after any side effects begin to wane.

Check-in Frequently

Don’t send a patient home with a prescription for a month’s worth of antidepressants and hope for the best. Depression is a potentially lethal illness. Patients need ongoing monitoring, especially until their antidepressants begin working. Schedule a follow-up no later than two weeks after therapy begins. Encourage patients also to check-in sooner via email if they have questions or experience troublesome side effects.

Weigh the Benefits of Changing Drugs

If a patient sees no improvement after four weeks, evaluate whether switching drugs, adding a new medication, or increasing the dosage is appropriate. If the patient has no serious side effects, a dosage increase may help. But if there’s been no relief at all, a different medication may be appropriate. Discuss various options with the patient, including potential side effects, and make the decision in collaboration with the patient.

Recommend Therapy

Though depression has physiological and biochemical components, it is not a purely physical disease. Correcting brain chemistry can help with some symptoms, but it may not relieve them all. And in some cases, it may offer little help at all. Depression treatment is most effective when it combines therapy and antidepressants. In therapy, patients master healthy lifestyle choices that can improve symptoms. They also gain a safe outlet for their emotions and assistance in managing any specific challenges that contribute to depression.

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Some patients are reluctant to try therapy because they believe medication is the fastest route to relief. Emphasize that therapy can change a person’s brain, too, and that both therapy and drugs act as medication. Indeed, in the early weeks, before drug therapy begins working, therapy can provide immense relief from rumination, guilt, and other painful depression symptoms.

Emphasize Lifestyle Changes

Depression attacks everything about the way a person lives. It can make healthy lifestyle habits feel nearly impossible. Yet these healthy lifestyle habits can also ease the symptoms of depression. Research consistently shows, for example, that regular exercise may be as effective as some antidepressants. Used in conjunction with antidepressants, then, exercise is powerful medicine.

Some other lifestyle changes to emphasize include:

• Better sleep hygiene, including getting up and going to bed at the same time each day
• A healthy, balanced diet that’s free of crash or fad diets
• Meditation
• Spending time on an enjoyable hobby
• Joining a support group

Re-Evaluate at Regular Intervals

Many patients remain stable on antidepressants for years. Others need to take them only for a few months and are then able to be weaned off. And some find that their antidepressants suddenly stop working. Schedule regular appointments to check in and re-evaluate the efficacy of treatment. Tweak treatment according to patient desires and needs, but emphasize that feeling better doesn’t necessarily mean the depression is gone. Rather, feeling better is a good sign that treatment is working.