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Clinical Review

Management of depression in adults

BMJ 2008; 336 doi: (Published 21 February 2008) Cite this as: BMJ 2008;336:435
  1. Markku Timonen, professor of general practice1,
  2. Timo Liukkonen, senior consultant2
  1. 1Institute of Health Sciences, University of Oulu, Box 5000, FIN-90014, Finland
  2. 2Department of Psychiatry, Savonlinna Central Hospital, Finland
  1. Correspondence to: M Timonen markku.timonen{at}

A study by the World Health Organization ranked depression the fourth global burden of disease and found it to be the largest non-fatal burden of disease, with nearly 12% of total years lived with disability.1 According to the cross sectional WHO world health survey, carried out in all regions of the world (60 countries), the one year prevalence of a depressive episode (international classification of diseases, 10th revision) was 3.2% (95% confidence interval 3.0% to 3.5%). In patients with several medical conditions the prevalence of depression exceeds that of the general population,2 with 5-10% of patients affected in primary care and 10-14% of patients under general hospital care.3 The diagnosis and treatment of depression by general practitioners is not, however, always optimal.4 5 We review the presentation and assessment of depression and discuss the options for its effective treatment and management.

Summary points

  • Somatisation is one of the most important single problems associated with a missed diagnosis of depression in primary care

  • Depression should be managed comprehensively and the efficacy of treatment evaluated for the first time within one month

  • When response to treatment is poor the diagnosis and compliance with treatment should be reassessed

  • Psychosocial treatments are first line treatments for mild depression

  • Structured psychological interventions, such as cognitive behaviour therapy and interpersonal therapy, and antidepressants are effective in moderate to severe depression

  • Evidence suggests that combined antidepressant and cognitive behaviour therapy is more efficacious than antidepressants alone in moderate to severe depression and chronic depression

Sources and selection criteria

We searched PubMed, the Cochrane database of systematic reviews, and citation lists of relevant publications using the subject headings and key words “depression”, “major depression”, “treatment”, “management”, “psychosocial”, and “pharmacological.” We also searched guidelines from the National Institute for Health and Clinical Excellence, the American Psychiatric Association, and the World Federation …

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