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ACP-ASIM issues guidelines for prescribing antidepressant drugs

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By American College of Physicians-American Society of Internal Medicine • • May 1, 2000

New guidelines for drug treatment of depression, released today by the American College of Physicians-American Society of Internal Medicine (ACP-ASIM), say that both older and newer antidepressant drugs are effective, and that St. John's wort may be effective in treating mild depression in the short term, but with caveats. "Depression strikes all ages, races, and income brackets. It's a very painful but very treatable illness, and there are many options available. It's important to talk to your doctor to determine the treatment that's best for you," says Herbert H. Waxman, MD, ACP-ASIM senior vice president for education.

To expedite doctor-patient discussions about depression, ACP-ASIM has developed a patient education brochure that is available by calling 1-877-828-2525. The information is also available on an ACP-ASIM Web site:

The guidelines, "Pharmacologic Treatment of Acute Major Depression and Dysthymia," and a background paper, "A Systematic Review of Newer Pharmacotherapies for Depression in Adults: Evidence Report Summary," are published in the May 2 issue of Annals of Internal Medicine.

The older drugs for treating major depression, such as tricyclics, and the newer drugs, such as selective serotonin reuptake inhibitors (SSRIs), have different side effects, interactions and costs. Patients taking tricyclics need dosage monitoring, and tricyclics can be fatal in overdoses. Tricyclics, most of which are available generically, are cheaper per pill. SSRIs and other newer drugs are not currently available in generic form and are generally more expensive. SSRIs are easier to take and do not require blood testing. Physicians should discuss with patients the uses and side effects of appropriate drugs, the guidelines say, and together, doctor and patient should come up with an antidepressant that fits the patient's needs.

ACP-ASIM recommendations about St. John's wort come with warnings. St. John's wort studies were mostly done in Europe. In the U.S., St. John's wort is sold as a dietary supplement, not as a drug, and therefore is not regulated by the FDA. The bottle labels can be misleading. The amounts of active St. John's wort ingredients vary in these supplements, and the pills often contain additional substances. Studies show that St. John's wort is better than placebo (a fake pill), but there are no good studies comparing St. John's wort directly with antidepressant drugs. Finally, St. John's wort has side effects, may interfere seriously with blood thinners and other important medications, and it should never be taken with other antidepressant drugs.

"We'll have to see more evidence-based studies on St. John's wort," says Waxman. "Meanwhile, if you are taking St. John's wort or any herbal supplement, let your doctor know."

While ACP-ASIM's new guidelines address drug treatment, depression can be treated in other ways, Waxman says. "Our guidelines are aimed at helping internists, together with their adult patients, make informed choices about treating depression with antidepressant drugs and herbal therapies."

The guidelines are appropriate for adult patients with no other medical conditions. ACP-ASIM did not find sufficient evidence to make recommendations for treatment of depression in adolescents or to treat other depressive disorders.

Amrican College of Physicians-American Society of Internal Medicine ACP-ASIM is a professional organization representing 115,000 internists, doctors for adults, and is the second largest medical organization in the U.S. It has been issuing evidence-based clinical practice guidelines for 20 years.

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