Mood disorders monograph offers advice on antidepressant use
WEB EXTRA! Prescribing tips for antidepressants Some might have considered it bad timing that the FDA issued an advisory on the use of antidepressants the same week that an AAFP monograph about mood disorders was in production.
AAFP editors thought it a fortuitous convergence of events.
Although the warning did push back the release of the monograph, authors of Diagnosis and Management of Mood Disorders were able to address the FDA's concerns in the 24-page publication, which the Academy is mailing this month to active members.
Robert Gillette, M.D., medical editor of the American Family Physician monograph, made the decision to delay production in March so the authors could review the content in the context of the newly released FDA advisory. Gillette, a professor of clinical family medicine at Northeastern Ohio Universities College of Medicine in Rootstown, said he wasn't surprised by the FDA warning.
"We've known since the 1970s that patients in the depths of depression may be too disorganized mentally to commit suicide, but as they start to improve, they may be able to summon enough energy to complete the act," he said.
Gillette stressed the need to start with a conservative dosage and titrate as necessary. "Any antidepressant use is an experiment in terms of risks and benefits," he said. "You might start on a low dose and work up, or switch to different antidepressants if one doesn't work."
He also emphasized the key point made by the FDA: Stay in contact with the patient. The monograph suggests checking in at one-week intervals in the early stages of treatment with an antidepressant.
Because of the FDA advisory, makers of 10 antidepressants will change the labels to include stronger cautions about the need to monitor patients for the worsening of depression and the emergence of suicidal ideation, said Christine Parker, FDA public affairs specialist.
"The advisory and labeling changes are intended to apply to any physicians and other health care providers who use antidepressants in treating either children or adults," Parker said.
Contrary to suggestions made in the lay press that the advisory would have a sobering effect on family physicians' prescribing practices, Gillette said FPs should remain confident.
"It shouldn't be a deterrent," he said. "Anybody in need of antidepressants is significantly ill and needs what it takes to get the job done.
"I think that the FP should be expected to have the same quality of end results as a psychiatrist does. The standard of care is close follow-up, which should be the same for the psychiatrist as for the family physician."
Furthermore, an FP is often a patient's best choice. A stigma remains to seeing a psychiatrist, Gillette noted, or there may be financial obstacles to seeing one.
What's more, a psychiatrist often doesn't have the benefit of knowing a patient's overall history. Family physicians have long known - and the monograph makes clear - that depression frequently occurs in patients who have other illnesses.
The monograph is an element of the AAFP's 2003 Annual Clinical Focus on Prevention and is supported by an educational grant from Wyeth Pharmaceuticals.
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
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