Some patients may need a drug that is 60 percent a serotonin modulator, 40 percent norepinephrine, or vice versa, or some other combination; others may need a drug that is dopamine-based, or works on other neurotransmitters.

The art of psychiatry, he says, lies in understanding the subtleties of the depression, the drugs and the side effects. A depressed person who also suffers from anxiety, for example, may become more anxious on antidepressants, even though antidepressants help treat anxiety. The trick, Tomb says, is to "start low, go slow" with the dose. "This is where a lot of family doctors get into trouble." Some doctors, too, may not realize that an antidepressant takes at least three weeks to begin working, and sometimes that long for side effects to disappear. Some may not understand that patients need to be monitored closely, especially when first beginning a new drug or changing doses; or that patients going off a drug must do so very gradually.

"There's an amazing amount of psychiatry they don't track," he says about family physicians. Many times, "they're prescribing whatever the latest drug rep visiting their office is pushing."

This means, he says, that the doctors may not realize that sometimes the older tricyclics and MAO inhibitors might work better for some cases of depression, although they do need to be monitored very carefully. Younger psychiatrists also tend to avoid the older drugs, he says.

Because the patents for the tricyclics and MAO inhibitors ran out long ago, they cost "pennies a day" — another reason why drug salesmen don't push them, Tomb says.

About 8 percent to 10 percent of depressed patients don't respond to any antidepressant, he says. That's when he might add lithium or thyroid medication to the mix, or might try electroconvulsive therapy.

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E-mail: jarvik@desnews.com