Treatment of Depression: A Systematic Review
Book. 2004 03
Authors: Swedish Council on Health Technology Assessment
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 (strong scientific evidence). 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 (strong scientific evidence). For the acute treatment of mild or moderate depression in adults, several types of psychotherapy are as effective as tricyclic antidepressants (TCAs) (strong scientific evidence) and probably as effective as selective serotonin reuptake inhibitors (SSRIs) (moderately strong scientific evidence). Antidepressants and electroconvulsive therapy (ECT) have proven to be most effective for severe depression, such as melancholia and psychotic depression (moderately strong scientific evidence). Antidepressants and ECT produce more rapid results than psychotherapy (moderately strong scientific evidence). Maintenance psychotherapy reduces or delays relapses, particularly in cases where acute antidepressant treatment or psychotherapy has not rendered the patient symptom free (strong scientific evidence). No significant differences have emerged in the effectiveness of various antidepressants for the treatment of mild and moderate depression (strong scientific evidence). Due to either side effects or lack of effectiveness, initial antidepressant treatment produces unsatisfactory results in an average of one third of the patients (strong scientific evidence). 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 (strong scientific evidence). 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 (strong scientific evidence). Sudden discontinuation of treatment with SSRIs, or TCAs that affect serotonin uptake, can cause severe withdrawal symptoms (moderately strong scientific evidence). 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) (strong scientific evidence). ECT is safe and effective, both more rapid and more effective than antidepressant treatment (strong scientific evidence). But there is a high probability of relapse, and only limited knowledge is available about which antidepressants are effective in preventing relapse (moderately strong scientific evidence). Transcranial magnetic stimulation (TMS) and vagus nerve stimulation (VNS) are experimental treatments that lack sufficient scientific basis for use in routine medical care. Light therapy has not been shown to be significantly more effective than placebos for treating seasonal affective disorder. St. John’s Wort (Hypericum perforatum) has been shown to be effective for short-term and mild depression (moderately strong scientific evidence), but its effectiveness in long-term treatment has not been studied. The preparation increases the metabolism of many common medications (including cholesterol lowering drugs, anticoagulants, oral contraceptives and immunosupressive drugs following organ transplants), as a result of which their effectiveness may be reduced or eliminated. Primary care studies in several countries produced better results than routine medical care when the provider offered patient instruction, telephone support and computerized reminders about treatment protocols, as well as ready access to psychiatrists and psychologists trained in short-term psychotherapy (strong scientific evidence). One antidepressant, (fluoxetine), has been shown to be effective for short-term treatment of depression in children and adolescents (moderately strong scientific evidence). No antidepressant has been approved in Sweden for treating that age group. Controlled long-term trials are completely lacking, though the risk of relapse after short-term treatment is just as high as in adults. There is moderate scientific support for treating depression in children and adolescents with cognitive behavioral therapy and interpersonal psychotherapy (moderately strong scientific evidence), but the long-term effectiveness is insufficiently documented. The effectiveness of antidepressant treatment and psychotherapy in the elderly up to the age of 75 is well documented (strong scientific evidence), but there are no studies of people over 80. Research on effective treatments for bipolar disorder has been very limited, and the results of the numerous trials now under way are not expected for several years. Lithium has been proven to be the most effective drug for the acute treatment of both manic and depressive episodes, as well as for preventive treatment (strong scientific evidence). Several new antipsychotic drugs have also been proven to be effective with acute manic episodes (strong scientific evidence), but there is only moderately strong scientific evidence for their preventive effect (moderately strong scientific evidence). Although some drugs originally developed to treat epilepsy are effective with both mania and depression (strong scientific evidence), only lamotrigine has been shown to have a preventive effect, primarily against depressive episodes (strong scientific evidence). There are several key areas in which research provides no basis for choosing a particular treatment. Studies are totally lacking when it comes to treating depression in people over 80. There are no studies of antidepressant treatment in children and adolescents that have lasted longer than 10 weeks, and documentation of the long-term effectiveness of psychotherapy in these age groups is very limited.