Remission as the Critical Outcome of Depression Treatment

Major depressive disorder is currently the fourth largest contributor to the worldwide burden of disease. Direct and indirect costs associated with depression place a significant burden on the healthcare system and society. Despite the development of new antidepressant medications, the management of patients with depression remains a therapeutic challenge. Obtaining a response in antidepressant therapy—commonly defined in clinical trials as an improvement of more than 50% from baseline total score of the Hamilton Rating Scale for Depression (HAM-D)—ensures little beyond a reduction from baseline in signs and symptoms. For example, incompletely remitted patients still experience psychosocial dysfunction and are at increased risk of relapse and recurrence. As in other diseases, the goal of treatment should be full remission rather than response, with full remission entailing complete resolution of symptoms and a full return to premorbid levels of functioning. Achieving and maintaining remission is ultimately the best pathway toward sustained recovery. Within this context, the relative benefits of various psychotherapeutic and pharmacological approaches to treatment are reexamined, taking into account issues such as design sensitivity and statistical power. Although results of individual studies are inconsistent, the findings of pooled analyses and meta-analyses suggest that combinations of psychotherapy and pharmacotherapy, and selection of antidepressants with potent effects on both serotonergic and noradrenergic neurotransmission, will increase the likelihood of remission.