The pharmacologic treatment of depression: drug selection criteria

Currently, the pharmacologic treatment of depression is undergoing significant changes that are aimed not only at resolving the acute episode but also at preventing relapse and enhancing the quality of life once full remission is achieved. In addition, the clinical observation of soft residual symptomatology after "full-blown" episodes and of the features of post-depressive personality with severe long-lasting maladjustment has expanded the concept of chronicity and duration in mood disorders. Developing a treatment strategy entails diagnosing the specific subtype of depression, establishing a threshold for initiating pharmacotherapy, and selecting an effective and safe antidepressant. Both the clinical features of the presenting episode and the longitudinal aspects of the mood disorder are relevant when one is defining subtypes of major depression. In 1989, the Pisa-Memphis Collaborative Study, which focused on patients presenting with a major depressive episode, clarified the role of soft indicators of bipolarity in defining subtypes of major depression. Combining a cross-sectional with a longitudinal evaluation can provide guidelines for choosing the most appropriate drug for a depressive episode that is often part of a comorbid condition. When selecting a pharmacologic treatment for the depressed patient, the physician must consider a number of factors, including, but not limited to, efficacy and safety. Although research has demonstrated that tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), atypical antidepressants, and selective serotonin reuptake inhibitors (SSRIs) are of comparable efficacy in patients with severe depression, SSRIs should be considered the agents of first choice for patients with comorbidity and chronicity, adolescents and young adults, and the elderly.(ABSTRACT TRUNCATED AT 250 WORDS)