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June 26, 1996

Treatment of Chronic Depression

Author Affiliations

Bowman Gray School of Medicine Winston-Salem, NC

JAMA. 1996;275(24):1883-1884. doi:10.1001/jama.1996.03530480025032

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