Severe depression - Is there a best approach?

A major depressive episode can be categorised as severe based on depressive symptoms, scores on depression rating scales, the need for hospitalisation , depressive subtypes, functional capacity, level of suicidality and the im pact that the depression has on the patient. Several biological, psychologi cal and social factors, and the presence of comorbid psychiatric or medical illnesses, impact on depression severity. A number of factors are reported to influence outcome in severe depression, including duration of illness before treatment, severity of the index epis ode, treatment modality used, and dosage and duration of and compliance wit h treatment. Potential complications of untreated severe depression include suicide, self-mutilation and refusal to eat, and treatment resistance. Several antidepressants have been studied in the treatment of severe depres sion. These include tricyclic antidepressants (TCAs), selective serotonin r euptake inhibitors (SSRIs), serotonin-noradrenaline (norepinephrine) reupta ke inhibitors, noradrenergic and specific serotonergic antidepressants, ser otonin 5-HT2 receptor antagonists, monoamine oxidase inhibitors, and amfebu tamone (bupropion). More recently, atypical antipsychotics have shown some utility in the manag ement of severe and resistant depression. Data on the differential efficacy of TCAs versus SSRIs and the newer antide pressants in severe depression are mixed. Some studies have reported that T CAs are more efficacious than SSRIs; however, more recent studies have show n that TCAs and SSRIs have equivalent efficacy. There are reports that some of the newer antidepressants may be more effective than SSRIs in the treat ment of severe depression, although the sample sizes in some of these studi es were small. Combination therapy has been reported to be effective. The use of an SSRI-T CA combination, while somewhat controversial, may rapidly reduce depressive symptoms in some patients with severe depression. The combination of an an tidepressant and an antipsychotic drug is promising and may be considered f or severe depression with psychotic features. Although the role of cognitive behaviour therapy (CBT) in severe depression has not been adequately studied, a trial of CBT may be considered in sever ely depressed patients whose symptoms respond poorly to an adequate antidep ressant trial, who are intolerant of antidepressants, have contraindication s to pharmacotherapy, and who refuse medication or other somatic therapy. A combination of CBT and antidepressants may also be beneficial in some pati ents. Electroconvulsive therapy (ECT) may be indicated in severe psychotic depres sion, severe melancholic depression, resistant depression, and in patients intolerant of antidepressant medications and those with medical illnesses w hich contraindicate the use of antidepressants (e.g. renal, cardiac or hepa tic disease).