Clinicians should specify subtypes of depression and combine antidepressants and psychotherapy

It is unlikely that different types of depression (primary versus secondary, diverse baseline scores on HAM-D) can be combined to one single disease called Major Depression. When testing the efficacy of antidepressants or psychotherapy, clinicians should make an attempt to specify the subtypes of depression and to combine antidepressants and psychotherapy (which should be much more mode-specific) in a sequential approach.

In the current issue of Psychotherapy and Psychosomatics, Professor Per Bech (Hillerod, DK) presents an innovative method for classifying depression in relation to response to treatment.

The official DSM-IV diagnosis of major depression, which is based on a cluster of symptoms, does not provide any information about the specific symptoms presented by the patient in question (e.g. typical versus atypical depression) and no information about aetiological factors (e.g. primary depression or depression secondary to stress or another medical condition). Medical disorders are conventionally classified on the basis of symptomatology, pathophysiology and aetiology. As the pathophysiological mechanism in depression is still unknown, the validity of DSM-IV major depression as a medical disorder is problematic. The severe primary depressive conditions (psychotic and bipolar depression) are considered to be the most typically medical disorders due to their genetic loadings but these conditions are excluded from the placebo-controlled trials of antidepressants. When reviewing the meta-analyses on the antidepressive effect of medication and psychotherapy, including the most comprehensive Sequenced Treatment Alternatives to Relieve Depression study (STAR*D), it was therefore obvious that only patients with very mild to moderate degrees of depression, typically with scores of 14 to 29 on Hamilton Depression Rating Scale (HAM-D) were treated. It is unlikely that these different types of depression (primary versus secondary, diverse baseline scores on HAM-D) can be combined to one single disease called major depression. Therefore, clinicians should make an attempt to specify the subtypes of depression when testing the efficacy of antidepressants or psychotherapy. Thus in the STAR*D study approximately 30% of the patients were atypical. In patients with major depression secondary to stroke, the symptom profile is that of typical depression with a clear superiority of selective serotonin reuptake inhibitors (SSRI) over placebo. In patients with mild major depression, including dysthymia, the effect of psychotherapy is less clear. However, attempts to combine antidepressants and psychotherapy in a sequential approach should be evaluated. In the stress-related depression the psychotherapies should be much more mode-specific.