Guidelines in major depressive disorder, and their limitations

Depression is a highly disabling, recurrent disease that imposes a significant burden on the individual, their close contacts, and on society. Despite the existence of treatment guidelines for major depression, management frequently falls short of these recommendations, sometimes due to inadequate doses or duration of prescribed antidepressant medication; at other times secondary to patient non-adherence to the recommended treatment. Evidence-based treatment guidelines developed by the major mental health organizations advise that patients who have experienced either a first or a recurrent episode of major depression should receive continued therapeutic doses of medication for at least 4-6 months following symptom remission, to reduce the risk of relapse. Further to this, antidepressant prophylaxis is beneficial in any patient with a history of three or more major depressive episodes, or two or more episodes in the last 5 years. Selective serotonin reuptake inhibitors (SSRIs) have demonstrated excellent efficacy and tolerability in the treatment and prophylaxis of major depression, as well as being associated with significant reduction in suicide risk in some populations. Escitalopram, an atypical SSRI that has shown superiority to conventional SSRIs and venlafaxine in clinical studies, has demonstrated particular benefits in severely depressed patients, in whom its efficacy appears to increase with increasing severity of depression. In the absence of formal treatment guidelines for severe depression, or comborbid depression and anxiety, escitalopram appears to be a logical treatment choice.