What are the primary goals and treatment options for depression in Canada?

Canadian Goals of Therapy for Depression

The primary goal of depression treatment in Canada is achieving complete remission—defined as virtually complete relief of symptoms AND return to full functioning in all areas of life—not merely symptom reduction or response. 1, 2

Defining Remission as the Treatment Target

Remission should be understood as the optimal outcome for initial treatment, encompassing both symptom resolution and functional restoration. 3 This is critical because:

• Residual symptoms (response without remission) are associated with significantly higher relapse rates 3
• Patients themselves prioritize return to their usual self, restoration of functioning, and presence of positive mental health features (optimism, self-confidence) as essential components of remission—not just absence of symptoms 4
• Only one-third of patients achieve full remission within 8 weeks of initial therapy, making aggressive treatment strategies necessary 3

Treatment Options to Achieve Remission

First-Line Approaches

Both pharmacologic and nonpharmacologic treatments offer similar efficacy, with selection based on patient preference, adverse event profiles, and symptom severity. 1

Pharmacotherapy

• Second-generation antidepressants (SGAs) are first-line medications, including SSRIs, SNRIs, bupropion, mirtazapine, and trazodone 1
• Initial dosing for sertraline (representative SSRI): 50 mg once daily for major depressive disorder, with dose increases up to 200 mg/day for non-responders 5
• More than 60% of patients experience adverse effects with SGAs, and up to 70% do not achieve remission during initial treatment 1
• Common side effects include sexual dysfunction, gastrointestinal symptoms, and sleep disturbances 1

Psychotherapy

• Cognitive Behavioral Therapy (CBT) is the most effective non-pharmacological treatment, with moderate-quality evidence showing similar efficacy to antidepressants and fewer side effects 2
• Third-wave CBT shows higher response and remission rates compared to antidepressants 2
• Interpersonal Therapy (IPT) has similar response and remission rates to SGAs after 12 weeks 2
• Psychotherapy, particularly CBT and behavioral activation therapy, may have superior relapse prevention effects compared to pharmacotherapy 6

Combination Therapy

Combined approaches (SGA plus CBT or SGA plus acupuncture) may improve treatment response and remission rates compared to monotherapy. 1, 2 This strategy is particularly valuable for:

• Moderate to severe depression 2
• Retaining quick medication results while gaining broader psychological intervention benefits 2

Complementary and Alternative Medicine

For mild to moderate depression, consider: 1, 2

• Acupuncture (similar response to fluoxetine monotherapy after 6 weeks) 2
• St. John's Wort (no difference in response/remission versus SGAs) 2
• S-adenosyl-L-methionine (SAMe) 1, 2
• Omega-3 fatty acids 1, 2
• Structured exercise programs (no difference in remission versus sertraline after 16 weeks) 2

Treatment Intensification Strategies

When initial treatment fails to achieve remission: 3

1. Ensure medication adherence before assuming treatment failure 3
2. Use maximally tolerated doses (higher than usual starting doses) 3
3. Switch to an antidepressant with multiple mechanisms of action 3
4. Combine dissimilar medications to treat a broader symptom range 3
5. Add psychotherapy to medication 3

Measurement-Based Care

Systematic assessment using validated tools is essential for achieving and maintaining remission: 7

• PHQ-9 (9-item Patient Health Questionnaire) for depressive symptoms 7
• QIDS-C or QIDS-SR (16-item Quick Inventory of Depressive Symptomatology) 7
• FIBSER questionnaire for side effect monitoring 7
• Assessments should occur at regular intervals to monitor progress toward remission, dosage efficacy, and tolerability 7

Treatment Duration and Phases

Acute Phase

• 6-12 weeks to achieve initial response 1

Continuation Phase

• 4-9 months following acute response 1
• For major depressive disorder, antidepressant efficacy is maintained for up to 44 weeks following 8 weeks of initial treatment 5

Maintenance Phase

• Several months or longer of sustained pharmacological therapy beyond initial response 5
• Patients should be periodically reassessed to determine need for continued treatment 5
• Chronicity and recurrence are the rule rather than the exception, requiring treatments with proven efficacy for preventing future episodes 6

Special Considerations

Comorbid anxiety and depression requires modified treatment approaches due to: 1

• More chronic illness course 1
• Increased suicidal thoughts and behaviors 1
• Greater functional impairment 1

Address stressful life events and comorbidities as these increase likelihood of depressive relapse and must be managed to prevent full relapse. 6

Critical Safety Monitoring

Antidepressants may increase suicidal thoughts or actions in children, teenagers, and young adults within the first few months of treatment or when doses change. 5 Monitor for:

• New or sudden changes in mood, behavior, actions, thoughts, or feelings 5
• Attempts to commit suicide, acting on dangerous impulses, thoughts about suicide or dying 5
• New or worse depression, anxiety, panic attacks, agitation, restlessness, anger, or irritability 5

Realistic Expectations

Remission rates in primary care range between 50-67% for active interventions, compared to 32% for placebo and 35% for usual care. 8 This makes remission a realistic and appropriate goal for family physicians treating depression in primary care settings. 8