Management of Depression

Abstract

To the Editor I read the review on management of depression in adults by Dr Simon and colleagues 1 with great interest. I would like to provide some supplementary information with regard to one of their references, and would also like to add a cautionary note on their use of the term "mild depression."With regard to the dose-response relationships of selective serotonin reuptake inhibitors, the authors contrasted our dose-response meta-analysis, which reported that higher doses did not increase the likelihood of response, 2 with that of a former systematic review, which found modest evidence for greater improvement at the upper end of recommended dosing ranges. 3 In the latter study, however, the majority of the included studies were flexible-dose studies in which clinicians could up-or down-titrate within a predesignated dose range and the maximum of the flexible dose range was used as the dose representing the treatment groups, whereas our meta-analysis was limited to studies with fixed-dose arms.Additionally, in their Figure, Simon and colleagues used the term "mild depression" when the Patient Health Questionnaire-9 (PHQ-9) score was less than 10. Upon careful review, I remain unsure whether the authors meant "mild major depression" or "subthreshold depression" with this term. If the former, it must be pointed out that the likelihood ratio for PHQ-9 scores between 5 and 9 to detect major depression is much smaller than 1.0, 4 meaning that someone with a pretest probability of major depression of 10%, for example, would have a posttest probability of actually having major depression of approximately 5%, or even less. If the authors meant to refer to "subthreshold depression" by using the term "mild depression," then it could be confusing to readers because "mild major depression" in this scheme would be termed "moderate depression." This may only be a matter of words or definitions, but I believe words would serve their purposes better if they were more clearly defined and in line with the standard diagnostic schemes.