Take Home Messages:

Depression is under recognised and undertreated.

Antidepressant medications are proven to work for the treatment of depression in the short and long term. They will typically alleviate symptoms but will not always ‘cure’ a person.

The treatment of depression depends on the severity, time course and the particular type of depression that someone has. Antidepressants will take varying amounts of time to work in different people and trials of different drugs may be needed. Some people will be resistant to treatment.

Counselling, psychotherapy and referral to specialists should all be part of a treatment program.

There are four principles for the treatment of depression:

1. Make a clear diagnosis.
2. Monitor the treatment program.
3. Aim to improve symptoms, return the patient to full functioning and prevent relapse.
4. Medication timing and duration should address short, medium and long term goals.

Why the research matters:

Major depression is one of the top ten causes of disability in the world. It is under recognised and undertreated.

Use of antidepressants is common and it is important to understand their effectiveness and how other treatments for depression can be used to complement pharmacological therapies. 

What the research involved:

Authors reviewed studies relevant to the treatment of major depression, including research on:

• Antidepressants; and
• Other treatments for depression, such as psychotherapy or psychopharmacology, including cognitive behavioural therapy (CBT), well-being therapy (WBT) and mindfulness-based cognitive therapy.

Summary of research findings:

The authors noted four principles in the treatment of depression.

1. Making a clear diagnosis is important. Use of questionnaires to accurately assess the symptoms and severity of symptoms is encouraged.
2. Having a reliable way of monitoring treatment progress is needed. Questionnaire use is also recommended
3. Clinicians should aim to achieve:
   • Improvement in the symptoms of depression;
   • A return to full function for the patient; and
   • Prevention of further episodes.
4. Timing and duration of medication:
   • Short term treatment should improve the condition within two to four weeks;
   • Medium term treatment for six to nine months is important to prevent relapse; and
   • Long term treatment is needed for some people to prevent recurrence of depression.

Regarding depression the authors point out:

• Risk factors for recurrence include a family history of mood problems, more than 3 previous episodes, an episode that lasts longer than 2 years, onset after age 60, and other health problems.
• Over 15 years, 90% of people who experience a severe episode of depression will have another depressive episode.
• Depression can be classified into various types and each type is managed slightly differently. Specialists may consider the use of other drugs and referral to specialist services is important.

Regarding antidepressants the authors point out:

• Acute attacks of major depression should be treated with antidepressants during the attack and for 6-9 months after to prevent another attack.
• Therapy should continue even in the absence of symptoms for the recommended time period.
• Patients at high risk will need to continue medication therapy indefinitely to prevent recurrence.
• It is important to remember that drugs affect everyone differently. Blood tests may be necessary to check the levels of some drugs used in the treatment of depression. Doses should be changed accordingly. Drugs that work for one person will not necessarily work for another.
• When trialling different medications patients should always receive the established minimally effective dose for the recommended period before changing drugs (unless the reason for change are unwanted side effects).
• Antidepressants should not be suddenly stopped. Their dose must be reduced over time.
• People often do not want to take antidepressants for extended periods. Clinicians need to educate patients about their importance.

Regarding cognitive behaviour treatment the authors point out:

• Counsellors have a role in the treatment of major depression, particularly in the long term.
• Well implemented cognitive behavioural therapy (CBT) over many sessions reduces the rate of relapse.
• Addressing problematic lifestyle factors and enhancing a person’s sense of wellbeing will further reduce relapse rates compared to CBT alone.
• Mindfulness therapy may be useful for people who are at high risk of relapse.
• Psychotherapy may be particularly useful for people with residual symptoms of depression.

Original Research

A Brief Review of Antidepressant Efficacy, Effectiveness, Indications, and Usage for Major Depressive Disorder

Nierenberg AA, Ostacher MJ, Huffman JC, Ametrano RM, Fava M, Perlis RH.

J Occup Environ Med. 2008;50:428–436

Link to PubMed abstract