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Supplements Trends in Managed Behavioral Healthcare: A Focus on Improving Depression Outcomes

Depression: The Benefits of Early and Appropriate Treatment

Aron Halfin, MD
Phase 1 results (n = 2876) indicated that only approximately 30% of patients met the criteria for remission during initial citalopram treatment. Response rates did not differ between patients treated in primary and psychiatric care settings. Remission, when it occurred, did so only after 8 weeks or more of treatment.32 In phase 2, augmentation of citalopram with sustained-release bupropion or buspirone led to similar rates of remission (39.0% and 32.9%, respectively). In those patients switched to another antidepressant therapy, approximately 25% had remission of symptoms after switching to sustained-release bupropion, sertraline, or extended-release venlafaxine, a serotonin norepinephrine reuptake inhibitor (SNRI).33

There are economic implications to switching between antidepressants. An analysis of a national pharmacy claims database indicated that switching from a failed antidepressant to another agent with a different mechanism of action (eg, SSRI to SNRI) resulted in reduced total healthcare costs, regardless of which drug class was attempted first.34 Costs declined after switching, but SSRI to SNRI switchers experienced a greater decline in total cost compared with SNRI to SSRI switchers.

To help clarify the selection of antidepressants in a managed care setting, Dunn and Tierney developed a step-therapy algorithm modeled partially after the STAR*D trial and based on trial data and the consensus statements of a panel of clinical and managed care professionals (Figure 3).25 The algorithm begins with the trial of an initial agent, followed by observation to determine the patient's response. If an inadequate response is achieved or if intolerable adverse events occur, options exist for dose escalation and/or augmentation as well as switching and/or discontinuation.20 In keeping with the body of evidence in depression treatment, remission is the end goal of the treatment outlined in the algorithm. Frequent follow-up visits or calls are promoted in the algorithm to continuously monitor progress in patients being treated for depression. When switching is deemed appropriate following 1 or 2 therapeutic failures in the same class, the panel recommends switching to an agent from a different class than the initial agent, in keeping with the body of evidence.20

Depression is a long-term and progressive condition that when not treated adequately can lead to severe morbidity and mortality and increased costs for payers, employers, and patients. Despite the significant burden of depression, the majority of patients do not receive treatment adequate enough to achieve remission. While remission is the primary goal of treatment, it is sometimes the most difficult to achieve. Effective strategies to achieve remission include an increase in dose, augmentation of medication, combination of psychotherapy and antidepressant treatments, or using medications with more than 1 mechanism of action. These strategies may be most easily applied through the use of a treatment algorithm. Patients who do not achieve remission, including those cycling on ineffective therapies, are at greater risk for relapse and recurrence, more long-term depressive episodes, and a shorter duration between depressive episodes. SSRIs are widely used first-line agents for the treatment of depression because of their efficacy, tolerability, and generic status, but when treatment fails, another class of antidepressants, such as an SNRI, should be attempted. Clinical trials provide good evidence to show that achieving and sustaining the fully remitted state is an attainable goal in the management of patients with depression.


Address correspondence to: Aron Halfin, MD, 3350 Peachtree Rd NE, Mail Stop G005-0001, Atlanta, GA 30326. E-mail:

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