Drug treatment of depression

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Olav Spigset, consultant (olav.spigset@relis.rit.no)a,
Björn Mårtensson, senior lecturerb

^aDepartment of Clinical Pharmacology, Regional and University Hospital, N-7006 Trondheim, Norway
^bDepartment of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Karolinska Hospital, S-171 76 Stockholm, Sweden

Correspondence to: Dr Spigset

Depression is a considerable mental health problem. It is often unrecognised or not properly treated and so causes distress, social impairment, and increased risk of mortality for the individual as well as large costs for society. However, several efficient treatments and strategies exist, of which antidepressant drugs are a main choice.

Summary points

In general, no antidepressant drug is clearly more effective than another

Outcome can be significantly improved by non-pharmacological factors, such as good therapeutic alliance between the doctor and the patient

A practical approach is to prefer newer antidepressants in mildly and moderately depressed patients and tricyclic antidepressants or venlafaxine in severely depressed patients

Antidepressants take 1-4 weeks before an effect is evident; this delay may be longer in elderly people

If patients do not respond, check compliance and reconsider the diagnosis before changing or adding drugs

After the initial treatment response, the drug should be continued at the same dose for at least 4-6 months

The dose should be gradually lowered over several weeks before withdrawal

Methods

This article is based on a review of recent research on the use of antidepressants in depression. Central research papers and authoritative, comprehensive, and recent reviews are cited.1 In areas of uncertainty, we make suggestions based on personal experience.

General considerations

Most patients with major depression (box)2 are best treated with a combination of antidepressants and psychotherapy. Some patients with mild to moderate major depression may be helped by supportive care, problem solving, or specific psychotherapy such as cognitive therapy alone. However, the fact that the symptoms seem to be a reaction to environmental factors does not preclude drug treatment per se.