Initiating Antidepressant Medication: What is the Most Important Factor?

Abstract

Treatment initiation is arguably the most important step in the management of depression. It is important at this stage of treatment to establish a therapeutic partnership between physician and patient, to facilitate shared decision-making. With specific regard to pharmacotherapy, negative attitudes and beliefs about antidepressant medications are common among the general public, and these can impact on how physicians who prescribe antidepressant medication are viewed. Some of these beliefs are that antidepressants are addictive, and that they change an individual’s personality. Before initiating treatment, it is important for physicians to understand the patient’s attitudes towards treatment, as well as their goals for treatment, especially since the patient’s goals may not be the same as the physician’s. Physicians can also identify patients who may be at risk of treatment resistance—those with more severe symptoms, at risk of suicide, with higher number of lifetime depressive episodes and comorbid anxiety disorder—and to differentiate treatment resistance from overlapping comorbidities. Patients need to understand that depression results from an interaction between biological and environmental factors; the use of analogies with other diseases, such as hypertension and/or a broken leg, can help in this regard. Finally, patients can be reassured that antidepressant medication is effective, and the range of agents currently available today target multiple pathways. While monotherapy is the goal, some patients will require additional treatments to manage comorbid psychiatric conditions (e.g. anxiety) or to achieve complete remission of depression. Only through complete remission of symptoms do patients achieve a level of psychosocial functioning that is equivalent to the non-depressed population. By explaining these factors to the patient, and listening to the patient’s beliefs, fears and goals, physicians can forge an effective therapeutic partnership for shared decision-making and maximise the chances of success from the time of treatment initiation.