exacerbation of suicidal ideation/intent as antidepressants are initially prescribed and begin to have psychotropic activity. Therefore, suicide assessments are of vital importance throughout the initial evaluation and ongoing treatment of a depressive episode.
Confirmation of the effectiveness of antidepressants is plentiful; however current pharmacotherapeutic management of depression is frequently flawed by inadequacies in dosage and duration.51,52 Non-adherence to prescribed medication occurs in part because of side effects, which usually begin before the therapeutic effect is achieved.53 Furthermore, medication is less tolerated by individuals with mild to moderate depression.54 In addition, individuals with major depression require continuing maintenance therapy to prevent setback. Adverse effects may be problematic for these individuals. A negative cognitive set may cause the individual with depression to see themselves, the future, and the world in a negative manner. This may cause them to expect poor outcomes and increase the risk for poor adherence.
If antidepressant medication is the treatment of choice, the individual must take the medication regularly for three to four weeks before the full therapeutic effect occurs.2 This may be an issue and will be discussed further in the section entitled “Adherence Challenges.”
It is critical that medications be assessed at regular intervals. Because many individuals with depression also have co-occurring medical issues, medication reconciliation must be performed on a regular basis. It may be beneficial for the interdisciplinary care management team to develop a treatment plan with the depressed individual with the following time frames:
Acute: This may last from 6 to 12 weeks, with the goal of remission of symptoms.
Continuation: This may last from 4 to 9 months, with the goal to prevent relapses.
Maintenance: The goal is to prevent recurrence.
If there is an inadequate response to medications prescribed, the healthcare professional prescribing the medication may re-evaluate the diagnosis, evaluate if side effects are problematic and adherence is an issue, determine if there is a need for increased dosing, change the medication, and add psychotherapy if not already in place.
Table 2 presents the major medications used to treat depression, along with their classes and mechanisms of action. There are a few pharmacological agents that offer blood monitoring tests, which may assist the treatment team in assessing efficacy or medication adherence.