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Am Fam Physician. 1999;60(6):1817

Between 4.6 and 8.6 percent of patients seen by family physicians have depression, but only about one third to one half of cases are detected during consultation. Recommended treatments for depression are frequently based on limited studies or projections from studies conducted in other clinical environments. A large Norwegian study provides new insights into effective therapy that combines medical treatment and psychologic support.

Sixty-one participating family physicians enrolled 372 patients who met the criteria for diagnosis of depression. The physicians had been trained in the diagnosis of depression and the use of standardized rating scales pertinent to the study. Additional training was provided in psychologic support techniques to provide the patients with the opportunity to describe symptoms and feelings, and to allow the family physicians to convey a sense of hope and optimism. No formal cognitive behavioral therapy was permitted during the study.

Patients were randomly assigned to receive sertraline, mianserin or placebo in a double-blind design. The initial sertraline dosage was 50 mg per day, increased to 100 mg per day during the third week of treatment. If necessary, the dosage was increased to a maximum of 200 mg per day during the sixth week. Initial mianserin therapy was 30 mg per day, increased after one week to 60 mg per day. If necessary, the dosage was increased to a maximum of 120 mg per day during the sixth week. Compliance was assessed by pill counts and determinations of drug plasma concentrations at eight and 24 weeks. Over 70 percent of patients completed 16 weeks of therapy and 64 percent completed all 24 weeks. The most common reason for withdrawal from the study was lack of clinical improvement, and this affected the placebo group for the most part. In the active treatment patients, 10 percent of those taking sertraline and 15 percent of those taking mianserin withdrew because of adverse side effects.

Based on intention to treat, 61 percent of patients randomized to sertraline and 54 percent randomized to mianserin achieved remission, compared with 47 percent of the placebo group. Although the initial response was more rapid to mianserin, a notably greater effect in patients treated with sertraline was established by the end of the study. Women responded better than men to active treatments, and patients with recurrent depression responded more frequently to sertraline.

The authors conclude that simple psychologic support plus active drug treatment provide higher rates of remission of depression in patients. Women and those patients with recurrent depression respond best to this combined therapeutic approach, but at least six months is required to evaluate effectiveness.

editor's note: Although demanding, depression can be one of the most rewarding conditions to treat in family practice. Besides its main conclusions of the efficacy of drug treatment and psychologic support, this study powerfully illustrates two key features of helping patients emerge from depressive illness. The first feature is the role of the physician. Nearly one half of patients treated with placebo responded to support from their family physician. The second is the necessity of perseverance with treatment at adequate dosage levels. A graph illustrating response over the course of the study indicates that at least six weeks of therapy with mianserin was necessary, and the response to sertraline was still improving at the end of the 24-week study.—a.d.w.

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