Evolutionary trends in the pharmacotherapeutic management of depression.

The past decade has brought an exponential increase in our knowledge of the pharmacotherapeutic management of depression. Much has been learned about the prevalence, risks, and course of depression in the general population, the elderly, and patients with comorbid medical illnesses and about the biological basis of depression. This article reviews evolving trends in the diagnosis and management of depression and evaluates the main classes of antidepressants. Although depression carries a high risk of morbidity and mortality, it is very treatable, and early diagnosis and early treatment are now emphasized. Antidepressant medication is continued after the patients' acute depressive symptoms resolve, sometimes for as long as 1 to 5 years to prevent relapse and recurrence of depression; in addition, full doses, rather than lower doses of antidepressant are prescribed for maintenance therapy. The armamentarium of antidepressants too has changed. In addition to monoamine oxidase inhibitors and tricyclic and tetracyclic antidepressants, the serotonin reuptake inhibitors fluoxetine, sertraline, and paroxetine are now available, as well as a group of antidepressants with atypical mechanisms of action that includes bupropion, trazodone, venlafaxin, and nefazodone. Although comparable in efficacy to the tricyclic antidepressants, these new drugs are safer and better tolerated because they are believed to act selectively on specific neurotransmitter systems.