To the Editor.
—Dr Goodwin1 raises numerous important points concerning the intricacies of managing depression in an era of increased managed care. However, Goodwin's suggestions for pharmacotherapy were somewhat surprising. Mr N apparently showed a partial response to imipramine, but did not do well on fluoxetine; we are unclear as to his response to bupropion. It also appears that Mr N's medications will have to be managed to a certain extent by his primary care physician.Given this, the rationale is not clear for retrying bupropion and then engaging in augmentation therapy, which is usually not a part of routine primary care practice. A different approach would be to try venlafaxine as a first choice, rather than as a second- or third-line agent, since it is a mixed reuptake inhibitor2 like imipramine, but as Goodwin mentioned, has a favorable adverse effect profile. This approach also would simplify treatment
Kelsey JE. Treatment of Chronic Depression. JAMA. 1996;275(24):1883–1884. doi:10.1001/jama.1996.03530480025032
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