Psychotherapy, social support essential to treat depression

Clinical depression is a major problem in the United States, affecting an estimated 5% to 10% of all adults. Costs for medical care and lost productivity related to depression are estimated at more than $40 billion per year.

Selective serotonin reuptake inhibitors (SSRIs) are the first choice for treatment for depression in both adults and children. There is no good evidence that any one SSRI is more effective than any other. "Jitteriness and insomnia early in treatment with SSRIs can be minimized by starting with low doses, possibly even lower than those recommended by the manufacturer for initial treatment," says Mark Abramowicz, MD, editor of The Medical Letter on Drugs and Therapeutics, a non-profit newsletter that critically appraises drugs.

CONTROVERSIAL BLACK BOX WARNINGS

Recent years have seen a great deal of concern about antidepressants possibly increasing the risk of suicidal behavior, particularly when prescribed for young people. In 2004, FDA began requiring drug companies to put black-box warnings on antidepressant labels, advising doctors and patients about potential increased risk in children and adolescents.

This warning has been highly controversial, and there's evidence it has led to a decline in antidepressant use among young people. In 2005, the American Medical Assn. adopted a resolution saying that antidepressants haven't been shown to increase the risk of completed suicide in children and adolescents, and that children should not be denied possibly life-saving medication.

"Medical Letter consultants believe that these drugs are much more likely to prevent suicide than to cause it. All depressed children, adolescents and adults, whether they are treated with drugs or not, should be monitored for suicidal ideation or behavior," says Dr. Abramowicz.

A recent meta-analysis of 27 studies on antidepressant use in adolescents found that the risk of suicidal thinking and behavior is lower than previously thought. This study, published in JAMA in April, found that for every 100 patients treated with antidepressant medications, less than one had an increased risk of suicidal thoughts. None of the studies found any completed suicides.

MANAGED CARE REACHES OUT

In addition to medication, psychotherapy, education and social support are essential parts of treatment for depression. "Our experience has shown that proactive assessment and early intervention combined with structured care coordination services enables optimal treatment outcome for our members," says Hyong Un, MD, national medical director for Aetna Behavioral Health.

With 15.7 million members covered by all of its medical plans, Aetna has developed two disease management programs for depression. The medical psychiatric program focuses on members who have both medical and behavioral health issues, using care managers to coordinate care between the two disciplines. The depression disease management program uses care managers to help members with depression access providers and use their pharmacy benefits effectively. Both programs rely on phone calls between patients and behavioral health clinicians, including nurses, licensed social workers, and psychologists. "We've found that members enrolled in these programs were more likely to follow up on treatment, report to work and meet job requirements consistently," says Dr. Un.