Access and Utilization of New Antidepressant and Antipsychotic Medications. National Guidelines


The AHCPR depression guidelines, published in 1993, describe a range of issues to be considered in the selection of a pharmacological therapy for depression. These guidelines specify that one of the SSRIs available at the time of publication (fluoxetine, sertraline, and paroxetine), bupropion, trazadone, or a secondary amine TCA (e.g., notriptyline, desipramine) are appropriate first-line choices for the treatment of depression. The guidelines also make specific recommendations regarding dosing of each type of agent, recognizing that TCAs are frequently underdosed. These guidelines recognize that the case for superior efficacy of any one single agent is not clear and that patient preference and physician experience should factor into the decision.

Similarly, the recommendations of the PORT focus on dosing and management of care.31 The guidelines recommend that an antipsychotic other than clozapine be used first line and that the dosing level be in the range of 300 -- 1,000 chlorpromazine equivalents per day for at least six weeks. Specifically the guidelines state

Since studies have found no superior efficacy of any antipsychotic medication over another in the treatment of positive symptoms, except for clozapine in the treatment-refractory patients, choice of the antipsychotic medication should be made on the basis of patient acceptability, prior individual drug response, individual side-effect profile, and long-term treatment planning.

Guidelines from The American Psychiatric Association for the treatment of both depression32 and schizophrenia33 are similar to guidelines discussed above. They provide general guidance to the physician on approach to treatment, but fall short of endorsing any one particular agent or class thereof. The APA depression guideline recommends that any non-MAO antidepressant is an appropriate first-line therapy for a patient with depression unless the patient presents with atypical depression or has had a prior good response to a MAO inhibitor. For patients with atypical depression either an SSRI or a MAO inhibitor is an appropriate first choice. The schizophrenia guideline recommends conventional antipsychotics and risperidone are reasonable first-line medications for patients in acute phases of schizophrenia. Although not completely reviewed at the time of publication, these guidelines recognize that olanzapine and quetiapine may fall into this category as well. The APA schizophrenia guidelines reserve clozapine for treatment-refractory schizophrenia.

Neither the NMHA nor NAMI endorse any particular treatment algorithm. The consumer associations generally believe that all drugs should be available on formulary and defer to the medical community for the choice of individual drugs for an individual patient.