Drug treatment of depression in medically ill patients

Depressive symptoms are common in medically ill patients although depressive disorders are considerably underdiagnosed and undertreated. Drug treatments for depression are reviewed in terms of a risk/benefit analysis. The main benefit is approximately to double the chance of recovery (from about 30 to 65%), with possible associated improvements in physical condition. The risks of treatment are considerable and include overdose, unwanted effects at therapeutic dose and interaction with other drugs. Among the risks associated with specific medical conditions are orthostatic hypotension, cardiotoxicity, deterioration of seizure control in epileptic patients and increased side effects in patients with renal and hepatic impairment. The available data suggest that there is relatively little to choose between antidepressants in terms of efficacy (although the quantity and quality of these data vary). It is therefore primarily the risks which should determine the choice of antidepressant, and these must be separately evaluated for each patient.