Treating depression: What to do and when to do it

Patients also find it frustrating that the treatment they have been taking has not been successful. And often it has been several treatments – since it is common to try antidepressants in sequence and find that, while sometimes being useful, none of them achieves a full recovery.

We can begin to address the problem with a good dose of psychoeducation. Insufficient attention to emotional and social aspects of depression reduces the chances of effective therapy. We should also be offering hope, and providing treatments that can mitigate the symptoms that are continuing to cause distress.

Rather than repeating what has not worked, we should consider options that target the constellation of remaining problems. One option is to add something to current therapy. If the index therapy has been insufficient, the next step should be guided by evidence. And there is consistent evidence from randomised controlled trials to support the efficacy of the adjunctive therapy approach. Patients too like the idea of building on progress already made.

In selecting a specific agent, we should of course choose one known to be effective. But safety and tolerability are also factors. Agents differ in their liability to cause weight gain and adverse metabolic changes – which are related but distinct problems – and in their tendency to cause either sedation on the one hand or restlessness and agitation on the other.  Patients fear all of these outcomes, and the risk that they may occur is cited as a barrier to treatment.

Involving patients in  setting the goals of treatment is an essential part of managing any chronic condition. I welcome the shift towards placing patients at the centre of the care plan, involving them in the setting of goals and in deciding how progress is to be assessed. It is incumbent on us to ask what aspects they are satisfied with and what aspects still need to be improved. Collaboration in the selection of care is also helpful in managing side effects.

In predicting the risk that a depressed patient will not achieve the goal of full functional recovery, clinical experience supported by research suggests several factors are important. And they are modifiable. The duration of the illness is one. Patients should not be left without initial treatment. And they should not be left on insufficiently effective treatment.

Deciding when to do something can be as important as deciding what to do. The longer a depressed patient is on suboptimal therapy, the lower the chance of achieving our objectives. Lack of improvement after 2-4 weeks is a loud and clear signal to intervene.