Objective: To review the pharmacological treatment of depression and to evaluate current strategies for treatment to maximize the benefits of antidepressant medications.
Quality of evidence: MEDLINE was searched to January 1999, using the headings depression, combination, augmentation, lithium, triiodothyronine, pindolol, buspirone, methylphenidate, and electroconvulsive therapy, for randomized controlled trials, systematic overviews, and consensus reports. Recent high-quality reviews were often found. References from papers retrieved were scrutinized for other relevant reports. Preference was given to more recent articles and well-designed studies. Recommendations from academic groups were analyzed.
Main message: Optimization of antidepressant therapy is the cornerstone of pharmacological treatment of depression. When symptoms persist despite optimization, further strategies include substitution, combination, augmentation, and reviewing and sometimes referring. Decisions are based on the evidence supporting the various strategies.
Conclusions: Antidepressants will work only if prescribed correctly. Awareness of the strategies for using antidepressants and evaluating their effectiveness improves primary care physicians' ability to treat this common disorder.