Pharmacological management of depression

Consider antidepressants for moderate-to-severe major
depressive disorder.

Antidepressants are effective for moderate-to-severe major depressive disorder (MDD). On the other hand, people with mild MDD are unlikely to benefit from an antidepressant.1,2 Non-drug treatments are first-line options in this patient group;3,4 however, such treatments need patient engagement to succeed.

For people with moderate-to-severe MDD, patients do better when an antidepressant is combined with cognitive-behavioural therapy (CBT) — e.g. relapse rates are likely to be lower.4,5
However, functioning may first need to improve to a level where patients can engage.

Which antidepressant?

A selective serotonin reuptake inhibitor (SSRI) is generally preferred as first-line treatment for moderate-to-severe MDD because the balance of benefits and harms is the most favourable among the different classes of antidepressant.4

Read NPS News 78 for information about selecting an antidepressant and non-response to antidepressant treatment.

How long should antidepressant therapy last?

Continue antidepressant treatment for 6–12 months after remission of symptoms to reduce the risk of relapse.4,6 Be aware that stopping treatment abruptly increases the risk of discontinuation symptoms — when stopping, taper the dose gradually.4,6

Additional psychological treatments after recovery, such as CBT or mindfulness therapy, are an option to reduce the risk of relapse and recurrence — especially for those who have multiple episodes of MDD.4,6

Read NPS News 78 for more information about how long to continue therapy.

References

  1. Fournier JC, DeRubeis RJ, Hollon SD, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA 2010;303:47–53. [PubMed]
  2. Kirsch I, Deacon BJ, Huedo-Medina TB, et al. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS medicine 2008;5:e45. [PubMed]
  3. Psychotropic Expert Writing Group. Therapeutic Guidelines: Psychotropic. Version 6. Melbourne: Therapeutic Guidelines Ltd, 2008.
  4. National Collaborating Centre for Mental Health (UK). Depression: the treatment and management of depression in adults (updated edition). Leicester (UK): British Psychological Society, 2010. http://www.ncbi.nlm.nih.gov/pubmed/22132433
  5. Cuijpers P, Dekker J, Hollon SD, et al. Adding psychotherapy to pharmacotherapy in the treatment of depressive disorders in adults: a meta-analysis. J Clin Psychiatry 2009;70:1219–29. [PubMed]
  6. Psychotropic Expert Writing Group. Therapeutic Guidelines: Psychotropic. Version 6. Melbourne: Therapeutic Guidelines Ltd, 2008.