Treatment of depression

Conclusions

• Treatment of depression should aim at full recovery, i.e., that the patient is not only symptom free but also able to fully function socially and at work. That objective can be achieved for the great majority of patients if available treatment options are consistently exploited (Evidence Grade 1).
• There are a large number of antidepressants and several types of psychotherapy that have been shown to be effective for treating major depression in adults (Evidence Grade 1).
• For the acute treatment of mild or moderate depression in adults, several types of psychotherapy are as effective as tricyclic antidepressants (TCAs) (Evidence Grade 1) and probably as effective as selective serotonin reuptake inhibitors (SSRIs) (Evidence Grade 2).
• Antidepressants and electroconvulsive therapy (ECT) have proven to be most effective for severe depression, such as melancholia and psychotic depression (Evidence Grade 2).
• Antidepressants and ECT produce more rapid results than psychotherapy (Evidence Grade 2).
• Maintenance psychotherapy reduces or delays relapses, particularly in cases where acute antidepressant treatment or psychotherapy has not rendered the patient symptom free (Evidence Grade 1).
• No significant differences have emerged in the effectiveness of various antidepressants for the treatment of mild and moderate depression (Evidence Grade 1).
• Due to either side-effects or lack of effectiveness, initial antidepressant treatment produces unsatisfactory results in an average of one-third of the patients (Evidence Grade 1).
• Once antidepressant treatment has resulted in remission, there is a high risk of relapse unless the same dosage is prescribed for at least another 6 months (Evidence Grade 1). Extension of the treatment to 1 year further reduces the risk of relapse. Prophylactic antidepressant treatment for as long as 3 years reduces the risk of recurrence by 50 percent in patients who suffer frequent or particularly severe depressive episodes (Evidence Grade 1).
• Sudden discontinuation of treatment with SSRIs, or TCAs that affect serotonin uptake, can cause severe withdrawal symptoms (Evidence Grade 2). But these symptoms do not indicate dependence, given that its classic signs – such as a significant dosage increase, preoccupation with tablet intake, or neglect of work, friends and normal interests – are absent.
• Antidepressants are more effective than psychotherapy for the treatment of chronic low-grade depression (dysthymia) (Evidence Grade 1).
• ECT is safe and effective, both more rapid and more effective than antidepressant treatment (Evidence Grade 1). But there is a high probability of relapse, and only limited knowledge is available about which antidepressants are effective in preventing relapse (Evidence Grade 2).
• Transcranial magnetic stimulation (TMS) and vagus nerve stimulation (VNS) are experimental treatments that lack sufficient scientific basis for use in routine medical care.