Antidepressant augmentation and combination in unipolar depression: strong guidance, weak foundations

Depression will be the second leading contributor to the global burden of disease by 2020. In Ireland, in 2009, 6061 people were hospitalised with depressive disorders. This represents a significant economic and social burden. There is growing awareness of the difficulty in treating depression with medications alone. The likelihood that a patient will achieve remission with the first antidepressant tried is around 30%, and the rates are similar for the second antidepressant tried. This falls to around 15% after three trials. Many patients are exposed to pharmacotherapy for extended periods of time with little beneficial effect, but often with side-effects. Patients are therefore in great need of clear information with regard to their chance of success. Clinicians are in need of clear guidance on prescribing strategies which have proven efficacy. However, this guidance often discusses treatment strategies based on varying levels of evidence. Guiding bodies may approach the problem from varying perspectives. The UK National Institute for Health and Clinical Excellence (NICE) has a clear government mandate with regard to provision of not only effective but cost-effective treatments. The British Association of Psychopharmacology (BAP) is an independent body of interested researchers and therefore may discuss prescribing options from the point of view of tertiary care institutions, and university centres. The South London and Maudsley NHS Foundation Trust publish the popular Maudsley guidelines. These are perhaps more pragmatic in nature, but include very low levels of evidence, including case series. The American Psychiatric Association (APA) is an independent member association which also publishes guidelines. These are published in the American Journal of Psychiatry and the latest guidelines were published in October 2010. All these bodies attempt to weigh their advice according to the level of evidence available and aim to provide clinical guidance in difficult situations. The burden on guiding organisations is to provide some direction and clarity in areas that are often unclear or controversial. Clinical guidelines are one method of providing support and guidance to busy clinicians. However, this clinician-centered approach has limitations. The onus is on the authors of the guidance to provide ever-more treatment options. This may mean that conclusions about the efficacy of medications is overstated or the limitations of the literature not fully explored in explanatory notes.