Strategies and Tactics in the Treatment of Depression - Tactical Issues

Treatment strategies involve the selection of the initial treatment and, for those who do not respond, subsequent treatments to be used. Tactics are the ways these treatment choices are implemented. Tactics include 1) careful attention to adherence, 2) selection among the available medications and psychotherapies, 3) careful evaluation of outcome, and 4) timely declaration of treatment failure if it occurs.

Pharmacotherapy
Monitoring adherence Adherence to treatment for depression is increased if patients are educated about treatment objectives and common strategies, if fewer daily doses are required (e.g., once-a-day vs. three-times-a-day dosing), and if a personality disorder is not present. Adherence is not related to gender, educational level, or socioeconomic status (Basco and Rush 1995). There is also some evidence that a greater frequency of visits (e.g., weekly versus biweekly), especially in the early stages of treatment, improves adherence. Whether or not the presence of other illnesses affects adherence is unclear. The best predictor of adherence is a history of adherence.

Thus, when medication is prescribed, it is advisable to discuss the objectives of treatment and the anticipated treatment period for attaining the objectives with patients and significant others. Difficulties with adherence are part and parcel of routine care, whether with medication, psychotherapy, or the combination; therefore, adherence checks should be a routine part of each visit. Obstacles to adherence should be anticipated and planned for, even before prescribing medication or initiating psychotherapy. Initial visits should be frequent enough to ensure adherence as well as timely interventions if untoward side effects are encountered. Often, one or more brief telephone contacts during the first several weeks after beginning medication will help adherence by reassuring patients, ensuring that severe side effects are avoided, countering demoralization and pessimism that may impair adherence, and providing information to overcome short-term concentration and recall problems that are part of the depressive episode. Adherence obstacles should be revisited routinely when beginning both the continuation and maintenance phases of treatment.

Choosing among medications If medication (alone or in combination with psychotherapy) is part of the first step, practitioners must select among a variety of medications that differ in their short- and long-term side effects but usually not in overall efficacy or time to response. Several recent reports (Anderson 1998; Clerc et al. 1994; Fawcett and Barkin 1998; Nutt 1998) suggest that in some patients, dual-action agents may be more effective than single-action agents. If the need for maintenance medication is anticipated, long-term side effects play a key role when selecting among medications.