Patients are becoming more informed about depressive disorders and their treatment. Still, some patients are adamantly opposed to medication, whereas others are equally opposed to psychotherapy. Patient preference can play a greater role when the empirical evidence does not strongly point toward a particular strategic choice (e.g., formal psychotherapy compared with medication). Although patients may exercise their first preference initially, a contingency plan, should the first treatment be ineffective, is best developed early in the management of the patient.
The heterogeneity among the mood disorders, as well as the array of potentially effective treatments, calls for careful strategic decision making and diligent application of the strategy chosen. However, no treatment is a panacea. The evidence suggests that only 45%-55% of patients who begin a medication, psychotherapy, or even the combination of both will respond well to the first acute-phase treatment trial. Response rates may be even lower for patients with more chronic (prolonged) major depressive episodes or for those with concurrent general medical or psychiatric disorders.
Consequently, it may be wise to initially plan for at least two acute-phase treatment trials at the outset so that patients may avoid being overly discouraged when there are still other options to be explored. This inappropriate discouragement may lead to attrition if the initial treatment is not tolerated or fails to provide full remission. Treatment tactics are used to obtain an optimal outcome and include specific attention to adherence; a careful titration of medications, when used, to attain maximal benefit with minimal side effects; and a careful symptom evaluation to ensure that remission, not just improvement, has occurred. Establishing explicit goals and following a stepwise plan or treatment algorithm may assist in attaining these goals, helping both practitioners and patients obtain the best outcomes.
Given the current plethora of treatment options for depression, it is logical that treatment algorithms (more specific guidelines) for major depressive disorder are becoming increasingly more available (Crismon et al. 1999; Rush et al. 1998). Whether such algorithms will provide better or more cost-efficient outcomes than treatment as usual is now being evaluated (Rush et al. 1999a, 1999b). Future challenges are sure to include whether different algorithms produce differential effects, as well as where to insert in the existing algorithms new treatments such as repetitive transcranial magnetic stimulation, vagus nerve stimulation, or substance P antagonists, should they prove to be safe and effective.
Revision date: June 20, 2011
Last revised: by Janet A. Staessen, MD, PhD