Pharmacological management of unipolar affective disorder

Unipolar affective disorder, or depression, is the one of the leading causes of disability worldwide and its effective management is a high priority. Treatment is required whether or not the illness is seen as ‘reactive’ to circumstances or understandable. Guidelines for its management have been produced by the National Institute for Health and Clinical Excellence (NICE) and the British Association for Psychopharmacology (BAP). These recommend rating the severity of the illness and using this as a guide for treatment. For less severe depression, antidepressants are recommended only when a patient fails to respond to other interventions or there is a history of more severe depression. For moderate-to-severe depression, antidepressants such as citalopram or fluoxetine are recommended as first-line treatments. The management of treatment-resistant depression (failure to respond to two adequate courses of antidepressants) is complex. NICE includes recommendations to consider augmentation of an antidepressant with cognitive behavioural therapy or lithium, monotherapy with venlafaxine or phenelzine (the latter particularly for atypical depression), and the combination of mirtazapine plus a selective serotonin reuptake inhibitor. BAP guidelines also include consideration of atypical antipsychotic or tri-iodothyronine augmentation of antidepressants. Other strategies have limited data supporting them and are not recommended, or are for use only in specialist centres.