General Issues
Defining Objectives
In selecting among acute-phase treatments, clinicians find that it is often useful to define the treatment objective(s) with patients. If they understand what to expect, they can better collaborate in determining whether or not the objectives are met. In addition, with defined objectives, clinicians can more clearly decide if the initial treatment choices were appropriate (i.e., were the objectives met?). As a result, subsequent strategic revisions in the treatment plan, such as switching or augmenting treatments or extending the treatment period, can be implemented in a timely fashion. The initial objectives of acute-phase treatment are symptom remission and restoration of psychosocial functioning, although the latter occurs sometimes weeks or even months after symptom improvement.

Determining When Formal Treatment Is Indicated
Milder, less chronic, less recurrent forms of major depressive disorder respond, and in some cases symptomatic remission occurs, without specific medication or even formal psychotherapeutic intervention. For example, Elkin et al. (1989) found that pill-placebo plus clinical management had an efficacy equal to that of imipramine in depressed outpatients with Hamilton Rating Scale for Depression scores less than 19, although the remission rates in the pill-placebo/clinical management cell tended to be somewhat lower than those in the medication cell. However, placebo responders fared poorly during the subsequent 18-month naturalistic follow-up study found that 50% of placebo responders largely maintained the response.

Strategies and Tactics in the Treatment of Depression Introduction Acute-Phase Treatment -General Issues -Strategic Issues -Tactical Issues -Treatment With Medication and Formal Psychotherapy Continuation-Phase Treatment Maintenance-Phase Treatment Patient Preference Conclusions Antidepressant and Antimanic Medications Depression-Focused Psychotherapies Psychodynamic Psychotherapies Combined Medication and Psychotherapy Electroconvulsive Therapy Light Therapy Treatment-Resistant Mood Disorders Treatment of Mood Disorders in the Medically Ill Patient

Patients with depressive disorder who have higher rates of response to nonspecific treatment generally have illnesses with less chronicity (fewer episodes, complete interepisode recoveries), fewer psychiatric and general medical comorbid conditions, and less severe symptom levels at initial evaluation. For these less severely ill patients whose illnesses are less chronic and complex, an extended evaluation of several weeks may be useful to assess the need for formal treatment. However, response to extended evaluation does not predict a uniformly good outcome over the longer course, so postresponse follow-up visits are desirable.

Selecting the Initial Treatment
Factors affecting the selection of the initial treatment include the chronicity of the depression, whether residual symptoms continue between full episodes, the history of recurrences (which predicts the likelihood of future recurrences), family history of illness, symptom severity, associated comorbid general medical or other psychiatric conditions, prior treatment responses to other acute-phase treatments, and patient preference. Note that for less severe, less complex depression, there is little evidence that the combination of medication and formal psychotherapy produces symptom relief greater than that obtained with either treatment alone. In general, the less severe, less chronic, and less complex the depression, the greater the role for patient preference, because evidence on which to base the selection between psychotherapy (time-limited, targeted type) and medication is largely absent.

Evaluating the Efficacy of the Initial Treatment
To fully evaluate the efficacy of the initial treatment, it is necessary to conduct a trial for a defined period and then to perform an assessment of whether the treatment has met the initial objectives. This assessment includes an evaluation of both the types and the severity of residual depressive symptoms and of psychosocial functioning. If the initial treatment must be discontinued because of intolerable side effects, a strategic revision is called for (e.g., switching to a new treatment or augmenting the current treatment). Randomized controlled trials reveal that only roughly 45%-55% of all outpatients with nonpsychotic major depressive disorder who begin treatment with medication, psychotherapy, or the combination (in nonchronic depression) will respond to the initial treatment. Consequently, roughly one-half of patients should anticipate a second treatment trial, because the initial treatment selected will be either intolerable or ineffective.