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Research ArticleEvidence-Based Clinical Medicine

The Symptom Cluster-Based Approach to Individualize Patient-Centered Treatment for Major Depression

Steven Y. Lin and Michael B. Stevens
The Journal of the American Board of Family Medicine January 2014, 27 (1) 151-159; DOI: https://doi.org/10.3122/jabfm.2014.01.130145
Steven Y. Lin
the Center for Education and Research in Family and Community Medicine, Division of General Medical Disciplines, Department of Medicine, Stanford University School of Medicine, Stanford, CA (SYL); and the San Jose–O'Connor Hospital Family Medicine Residency Program (affiliated with Stanford University School of Medicine), San Jose, CA (SYL, MBS).
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Michael B. Stevens
the Center for Education and Research in Family and Community Medicine, Division of General Medical Disciplines, Department of Medicine, Stanford University School of Medicine, Stanford, CA (SYL); and the San Jose–O'Connor Hospital Family Medicine Residency Program (affiliated with Stanford University School of Medicine), San Jose, CA (SYL, MBS).
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Article Figures & Data

Tables

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    Table 1. Commonly Prescribed Antidepressants in Primary Care
    Generic NameUS Trade NameClass*Dosage FormsUsual FrequencyPregnancy Category†Breastfeeding Safety‡Generic AvailableRetail Available§Cost‖
    AmitriptylineElavilTCATabletOnce a dayCNRYesYes$
    BupropionWellbutrinNDRITabletThree times dailyCNRYesNo$$
    Wellbutrin SRTwice a dayYesNo$$
    Wellbutrin XLOnce a dayYesNo$$$
    CitalopramCelexaSSRITablet, solutionOnce a dayCR:BYesYes$
    DesvenlafaxinePristiqSNRITabletOnce a dayCNRNoNo$$$$
    DuloxetineCymbaltaSNRICapsuleOnce a dayCNRNoNo$$$$
    EscitalopramLexaproSSRITablet, solutionOnce a dayCR:BYesNo$$$
    FluoxetineProzacSSRITablet, capsule, solutionOnce a dayCNRYesYes$
    Prozac WeeklyCapsuleOnce a weekYesNo$$$
    Fluvoxamine¶LuvoxSSRITabletTwice a dayCR:BYesNo$$$
    Luvox CRCapsuleOnce a dayNoNo$$$$
    Milnacipran¶SavellaSNRITabletTwice a dayCNRNoNo$$$
    MirtazapineRemeronNaSSATabletOnce a dayCR:BYesNo$
    Remeron SolTabOral disintegrating tabletYesNo$$
    Nefazodone**SerzoneSARITabletTwice a dayCNRYesNo$$
    NortriptylinePamelorTCACapsule, solutionOnce a dayDNRYesYes$
    ParoxetinePaxilSSRITablet, solutionOnce a dayDSafeYesYes$
    Paxil CRTabletYesNo$$$
    SertralineZoloftSSRITablet, solutionOnce a dayCSafeYesYes$
    TrazodoneDesyrelSARITabletThree times dailyCR:BYesYes$
    OleptroOnce a dayNoNo$$$
    VenlafaxineEffexorSNRITabletTwice a dayCNRYesNo$$
    Venlafaxine EROnce a dayYesNo$$$
    Effexor XRCapsuleOnce a dayNoNo$$$$
    Vilazodone††ViibrydSPARITabletOnce a dayCNRNoNo$$$$
    • ↵* TCA, tricyclic antidepressant; NDRI, norepinephrine dopamine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; SNRI, serotonin norepinephrine reuptake inhibitor; NaSSA, noradrenergic specific serotonergic antidepressant; SARI, serotonin antagonist reuptake inhibitor; SPARI, serotonin partial agonist reuptake inhibitor.

    • ↵† C, no adequate or well-controlled studies in humans; D, positive evidence of human fetal risk based on adverse reaction data or studies in humans.

    • ↵‡ NR, not recommended; R:B, weigh risk-benefit; safe, safe for nursing; based on Lexicomp Online Clinical Databases (http://online.lexi.com).

    • ↵§ Available for a low monthly cost through programs offered by large chain stores (e.g., Walmart, Kroger, Sam's Club, Target, Costco, CVS, Kmart, Walgreens).68

    • ↵‖ $ = <$50 per month; $$ = $50 to $100 per month; $$$ = $100 to $150 per month; $$$$ = >$150 per month; based on 2011 Consumer Reports Health Best Buy Drugs.68

    • ↵¶ In the United States, fluvoxamine is approved only for obsessive-compulsive disorder; milnacipran is approved only for fibromyalgia; both agents are used off-label to treat depression.19,24

    • ↵** Serzone, the brand name form of nefazodone, was discontinued in 2004 because of hepatotoxicity; generic nefazodone is available with a black box warning for liver failure.57

    • ↵†† Approved in 2011, vilazodone is the newest antidepressant in a novel therapeutic class; given that data is limited, it is not discussed in this article.

    • View popup
    Table 2. Recommended Treatment for Depression with Anxiety
    Symptom ClusterRecommended ClassesClasses to AvoidFirst-line Antidepressants
    AnxietySSRINDRICitalopram
    TearfulnessSNRIEscitalopram
    Obsessive-compulsivenessFluvoxamine
    Sertraline
    • NDRI, norepinephrine dopamine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; SNRI, serotonin norepinephrine reuptake inhibitor.

    • View popup
    Table 3. Recommended Treatment for Depression with Fatigue
    Symptom ClusterRecommended ClassesClasses to AvoidFirst-line Antidepressants
    FatigueNDRINaSSABupropion
    AnhedoniaSNRISARIDesvenlafaxine
    Weight gainActivating SSRIFluoxetine
    Venlafaxine
    • NaSSA, noradrenergic specific serotonergic antidepressant; NDRI, norepinephrine dopamine reuptake inhibitor; SARI, serotonin antagonist reuptake inhibitor; SNRI, serotonin norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor.

    • View popup
    Table 4. Recommended Treatment for Depression with Insomnia
    Symptom ClusterRecommended ClassesClasses to AvoidFirst-line Antidepressants
    InsomniaNaSSANDRIMirtazapine
    HyperarousalSARISNRINefazodone
    Weight lossSedating SSRIParoxetine
    Trazodone
    • NaSSA, noradrenergic specific serotonergic antidepressant; NDRI, norepinephrine dopamine reuptake inhibitor; SARI, serotonin antagonist reuptake inhibitor; SNRI, serotonin norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor.

    • View popup
    Table 5. Recommended Treatment for Depression with Pain
    Symptom ClusterRecommended ClassesClasses to AvoidFirst-line Antidepressants
    Chronic painTCANoneAmitriptyline
    HeadacheSNRIDuloxetine
    SomatizationMilnacipran
    Nortriptyline
    • SNRI, serotonin norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant.

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The Journal of the American Board of Family     Medicine: 27 (1)
The Journal of the American Board of Family Medicine
Vol. 27, Issue 1
January-February 2014
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The Symptom Cluster-Based Approach to Individualize Patient-Centered Treatment for Major Depression
Steven Y. Lin, Michael B. Stevens
The Journal of the American Board of Family Medicine Jan 2014, 27 (1) 151-159; DOI: 10.3122/jabfm.2014.01.130145

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The Symptom Cluster-Based Approach to Individualize Patient-Centered Treatment for Major Depression
Steven Y. Lin, Michael B. Stevens
The Journal of the American Board of Family Medicine Jan 2014, 27 (1) 151-159; DOI: 10.3122/jabfm.2014.01.130145
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