Case Study 10: Depression

September 2000

Scenario Mrs Bond is a 46 year old who is agitated, and complains of appetite loss and low mood over the previous two months. During the examination she is teary, complains of inability to sleep, and loss of interest in work and leisure activities. She has been stressed and unable to function at work. The patient denies any suicidal thoughts. Physical examination and other investigations are normal, and the diagnosis of major depression is made. You agree with Mrs Bond to schedule a series of appointments for counselling. Because of the severity of the symptoms, which meet diagnostic criteria for major depression, you decide to initiate antidepressant therapy.

Inside Results In summary In detail

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Expert commentaries Dr Bill Lyndon

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A/Professor Dimity Pond

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Case Study Results Results in summary 1119 responses were received to this case study and the aggregate results of two hundred responses were compiled for feedback.

Most respondents (74%) prescribed a selective serotonin reuptake inhibitor (SSRI) as initial antidepressant therapy. Sertraline (35%) and paroxetine (21%) were the most common. Tricyclic antidepressants (TCAs) were chosen for 11% of respondents and nefazodone, moclobemide and venlafaxine, combined, accounted for 14%. Over 88% of respondents indicated their choice of antidepressant was influenced by efficacy and adverse effect profiles. Reasons specified included proven effectiveness, past prescribing success and lower incidence of adverse effects with the SSRIs and newer antidepressants. Most prescribers (84%) of SSRIs would discuss the frequent adverse effects with the patient and of these 13% would also provide management advice for adverse effects, especially if symptoms persisted after 1-2 weeks. All the prescribers of nefazodone, venlafaxine and moclobemide would provide the patient with specific adverse effects. Half of these prescribers would also discuss management of adverse effects. The prescribers of TCAs would discuss the common adverse effects and included the warning to avoid alcohol and /or caution about driving machinery. Other important information given to the patient included delay in onset of action, timeframe of treatment, and importance of compliance. The majority of respondents would not prescribe any other drug therapy (64%). Of the 36% who would prescribe other drug therapy, 32% would prescribe a concomitant benzodiazepine. Only 4% indicated they would change antidepressant therapy if initial choice gave a poor response. Most respondents would maintain antidepressant therapy for a minimum of six months after initial response.

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Results in detail Question 1 What would you prescribe as initial antidepressant therapy?

Choice of antidepressant and starting doses are shown in the table below. Drug

Brand name

Starting dose

SSRIs Sertraline1

Zoloft

Citalopram2

Cipramil

Paroxetine1

Aropax

Fluoxetine

Lovan, Prozac, Zactin Auscap, DBL or SBPA Fluoxetine, Fluohexal Luvox, Faverin 100

Fluvoxamine

Other newer antidepressants Nefazodone2 Serzone

Venlafaxine

Efexor XR

Reversible monoamine oxidase A inhibitor Moclobemide Aurorix, Arima, DBL Moclobemide

Tricyclic antidepressants Dothiepin Dothep, Prothiaden

Nortriptyline Trimipramine Amitriptyline3

Allergon Surmontil Endep, Tryptanol, Tryptine, Amitrol Doxepin3 Deptran, Sinequan Other antidepressant therapy Mianserin Lumin, Tolvon Other drug therapy Murelax, Serepax, Oxazepam5 Alepam 1 2 3 4 5

25mg daily 25mg–50mg daily 50mg daily 50mg-100mg daily 10mg daily 10mg-20mg daily 20mg daily 10mg daily 10mg-20mg daily 20mg daily 20mg daily

1 2 30 2 1 2 8 3 1 17 5

50mg daily 100mg daily

1