When should you move beyond first-line therapy for depression?
The probability of achieving and sustaining symptomatic remission in major depressive disorder (MDD) with first-line pharmacotherapy is approximately 30%. Ample documentation shows that the maximal therapeutic effect obtained with antidepressant pharmacotherapy is approximately 4 to 6 weeks, perhaps longer for individuals receiving manual-based psychotherapies. Emerging evidence also indicates that early (ie, at 2 weeks) symptomatic improvement (ie, ≥ 20% improvement on the 17-item Hamilton Depression Rating Scale score) positively predicts remission at weeks 6 to 8 (nonimprovement at week 2 may be a more robust negative predictor of nonremission at weeks 6 to 8). Notwithstanding the identification of early positive/negative remission prediction, a subgroup of individuals receiving pharmacotherapy evinces initial improvement beyond week 6 of treatment. Available evidence does not support a claim that any antidepressant or class of antidepressants offers a faster onset of action. Identifying moderators and/or predictors of response is a priority research vista; hitherto, no biomarker has emerged as a reliable predictor of treatment efficacy, tolerability, or safety. Emerging evidence suggests that electrophysiological measures, ie, frontal quantitative electro encephalography (QEEG) may be capable of identifying antidepressant remitters within 1 to 2 weeks of exposure. Taken together, practitioners are often faced with the critical question as to when to move beyond index therapy for treating depressive symptoms as part of MDD.
Department of Psychiatry, University of Toronto, Toronto, ON, Canada. roger.mcintyre@uhn.on.ca
Roger S
RS
McIntyre
D000928:Antidepressive Agents / Q000008:administration & dosage*; D014150:Antipsychotic Agents / Q000627:therapeutic use; D003865:Major Depressive Disorder / Q000188:drug therapy* / Q000628:therapy; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D006801:Humans; D011569:Psychiatric Status Rating Scales; D011613:Psychotherapy / Q000379:methods; D012074:Remission Induction / Q000379:methods*; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors
D000928:Antidepressive Agents; D014150:Antipsychotic Agents