Evidence-Based Selection and Use of Antidepressants in Psychiatric Practice

Abstract

Depressive disorders (DD) are serious psychological diseases, which are widespread, of early onset, with a risk of chronicization, frequent comorbidities, including alcohol abuse, cardiovascular diseases, suicidal tendencies, and aggressive behavior, along with decreases in patients' quality of life, all of which result in DD imposing a severe burden on society [1-3] and making assessment of the resource-sparing potential from the medical and social perspectives important [4][5][6]. Thus, in 2002, when the total number of cases needing assistance was 20-30 times smaller, the total medical costs of DD in the capital's psychoneurological clinics (PNC) accounted for 0.02% of the gross regional product of Moscow; social losses constituted 90% of the burden of DD, emphasizing the importance of optimizing the treatment of this type of mental pathology [7].The burden of DD is exacerbated by the insuffi cient effi cacy of psychopharmacotherapy even in countries with outstanding systems for standardized psychiatric care [4,[8][9][10]. No more than 50-60% of those needing treatment receive it, including severe cases [2,8,11]; the average treatment delay is three years [11]. Krasnov et al. [12] found that of 9988 patients attending reginal polyclinics, DD was present in 30%, though only 10% were receiving minimal courses of SSRI. The literature also contains data [4,13] showing that 70-80% of antidepressants were prescribed by inadequately trained general practitioners.Most patients receive inadequate treatment [2,14]. Patients attending PNC are generally (>60%) treated with subtherapeutic doses mainly of fi rst-generation tricyclic antidepressants (TCA) for less than three months, combined with sedative neuroleptics and tranquillizers on a constant basis; the better the provision of the psychiatric institution with medications, the more intricate the scheme of pharmacotherapy (sometimes including 3-5 drugs as 3-4 daily doses, without consideration of their half-elimination periods), which leads to an increase in the risk of undesirable effects, which elevates treatment costs without enhancing effi cacy [4,8]. The costs of second-line agents for the treatment of DD are greater than those for antidepressants. Archaic and complex patterns of antidepressant therapy generate additional stigmatization of psychiatric care, such that patients reject it. It is not by chance that 20% of those attending consultations for DD return to the PNC within a year [4,8]. The Russian standard (draft) for the treatment of DD in PNC and hospital conditions, discussing current poor practice, evoked a number of justifi able comments on the Russian Society of Depressive disorders (DD) have a high risk of recurrence and involve impairments to patients' daily and social functioning and quality of life; these factors result in a high socioeconomic burden. Optimization of antidepressant use on the basis of the risk:benefi t ratio and evidence-based resource-sparing potential is important for lightening of the load of DD, along with targeted psychosoci...