What is the recommended treatment for other depressive disorder?

Treatment for Other Depressive Disorder

For other depressive disorders (including subsyndromal depression, minor depression, and dysthymia), antidepressants should NOT be routinely prescribed as initial treatment; instead, consider psychological interventions or watchful waiting, as antidepressants show minimal to no benefit over placebo in the absence of a current moderate or severe depressive episode. 1

Key Diagnostic Distinction

The term "other depressive disorder" encompasses depressive symptoms that do not meet full criteria for major depressive disorder (MDD), including:

• Subsyndromal depression - fewer than 5 symptoms or symptoms lasting less than 2 weeks 1
• Minor depression - depressive symptoms without meeting MDD threshold 1
• Dysthymia - chronic low-grade depression 1

This distinction is critical because treatment recommendations differ substantially from MDD.

Evidence Against Antidepressants for Mild/Subsyndromal Depression

• In patients with depressive symptoms without a current moderate or severe depressive episode, there is unlikely to be a clinically important difference between antidepressants and placebo 1
• The drug-placebo difference for antidepressants increases only as a function of initial severity, rising from virtually no difference in mild depression to small differences in moderate depression and medium differences in severe depression 1
• The American College of Physicians explicitly states that antidepressants should not be considered for initial treatment of adults with depressive symptoms in the absence of current or prior moderate or severe depressive episode 1

Recommended Treatment Approach

First-Line Options

Psychological interventions should be the primary consideration:

• Cognitive Behavioral Therapy (CBT) has moderate-quality evidence supporting effectiveness comparable to antidepressants in MDD, making it particularly appropriate for milder presentations 2
• Interpersonal therapy is an effective alternative 2
• Psychodynamic therapies may also be considered 2

Monitoring and Reassessment

• Use validated assessment tools (PHQ-9, HAM-D) to objectively measure symptom severity and track progression 2
• Reassess within 1-2 weeks to determine if symptoms are worsening or meeting criteria for moderate-to-severe MDD 1
• If symptoms progress to moderate or severe MDD, then pharmacotherapy becomes appropriate 1

When to Consider Pharmacotherapy

Antidepressants become appropriate only when:

• Symptoms meet full criteria for moderate or severe MDD (at least 5 symptoms for ≥2 weeks with functional impairment) 2
• Patient has history of prior moderate or severe depressive episodes 1

If Pharmacotherapy Becomes Indicated

Second-generation antidepressants (SSRIs preferred) are first-line:

• Sertraline, escitalopram, fluoxetine, paroxetine, or citalopram 2
• SSRIs have lower toxicity in overdose compared to tricyclics 2
• Monitor closely beginning within 1-2 weeks of initiation 1
• Modify treatment if inadequate response within 6-8 weeks 1

Common Pitfalls to Avoid

• Do not prescribe antidepressants reflexively for any depressive symptoms - this leads to overtreatment of conditions unlikely to benefit 1
• Do not assume all depression requires medication - the evidence clearly shows minimal benefit in mild/subsyndromal presentations 1
• Do not delay psychological interventions - these are effective and avoid unnecessary medication exposure 2
• Do not fail to reassess severity - symptoms may evolve to require different treatment 1

Special Populations

In children 6-12 years with depressive symptoms, antidepressants should not be used in non-specialist settings 1

In adolescents with depressive episodes, only fluoxetine (not TCAs or other SSRIs) may be considered in non-specialist settings, with close monitoring for suicidal ideation 1