These policy decisions have illustrated the need for better methodical approaches for risk assessment (see below). Phases of Stattic mouse treatment In developing a treatment strategy, it is useful for the clinician to consider treatment of major depression as involving three phases: acute, continuation,

and maintenance (if appropriate). The goals of the acute phase are to achieve remission (resolution of all symptoms) and restore functioning (Table III).17,18 During this period, continued follow-up visits are essential The goal of the continuation phase is sustained remission. Unfortunately, only recently has renewed attention been devoted to the issue of response versus Inhibitors,research,lifescience,medical remission. Failure to achieve complete remission (recovery) has major adverse consequences including the following: increased risk of relapse19 and treatment resistance; persistent functional impairment20; sustained risk of suicide; worsened morbidity of other psychiatric conditions; and medical disorders. Inhibitors,research,lifescience,medical This phase should last approximately 6 months following full remission of the acute episode. Then, the patient in

whom the risk for recurrence is low should be gradually tapered from treatment over a period of 1 to 3 months. Rapid discontinuation of virtually all antidepressants, including those with long half-lives, tends Inhibitors,research,lifescience,medical to be associated with symptomatic relapse. Since the majority of depressed individuals suffer from recurrent depression, the physician should consider the appropriateness of a maintenance phase. Data on long-term treatment in the psychiatric specialty sector indicate that maintenance treatment should be sustained for a minimum of 3 to 5 years. Unfortunately, there Inhibitors,research,lifescience,medical are no such21-23 studies in primary care to determine appropriate duration of long-term treatment in this setting. Table III. Depression medication algorithms. Contact may be in person or by telephone. Reproduced from Rush AJ et al (The Texas Medication Algorithm Project), personal communication. Available medications and their use in acute treatment There Inhibitors,research,lifescience,medical is no paucity of medications approved by the Food and Drug Administration (FDA) for a depression

indication. One of the two initial classes Montelukast Sodium was the tricyclic anti-depressants (TCAs), a family of structurally related compounds with reuptake inhibitory properties on brain monoamine metabolism. All the TCAs are potent blockers of NE reuptake (except for clomipramine which highly serotonergic, but is approved by the FDA only for treatment of obsessive-compulsive disorder) and weak blockers of 5-HT reuptake. The second original class of drugs, the monoamine oxidase inhibitors (MAOIs), have never been widely prescribed because of real (and sometimes exaggerated) concerns about safety, despite their established efficacy in certain subtypes, especially atypical and bipolar depression.24,25 A majority of the newer compounds are considered to be SSRIs.