Next Article in Journal
Evaluating Major Bleeding Risks with Concomitant Use of Direct Oral Anticoagulants and Selective Serotonin Reuptake Inhibitors in Nonvalvular Atrial Fibrillation Patients
Previous Article in Journal
A Systematic Review of Potential Opioid Prescribing Safety Indicators
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Pharmacoepidemiology
Volume 4
Issue 1
10.3390/pharma4010005
pharmacoepidemiology-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Challenges in Managing Depression in Clinical Practice: Result of a Global Survey

by
Nilamadhab Kar
1,2
1
Black Country Healthcare NHS Foundation Trust, Wolverhampton WV10 9TH, UK
2
Research Institute in Health Sciences, University of Wolverhampton, Wolverhampton WV1 1LY, UK
Pharmacoepidemiology 2025, 4(1), 5; https://doi.org/10.3390/pharma4010005
Submission received: 27 December 2024 / Revised: 30 January 2025 / Accepted: 14 February 2025 / Published: 18 February 2025
Review Reports Versions Notes

Abstract

:
Background/Objectives: Despite an improved knowledgebase, effective intervention, and guidelines, many patients with depression do not receive adequate treatment and treatment discontinuation and non-response are common. It was intended to explore the challenges clinicians face while managing depression in their clinical practice and their suggestions for solutions. Methods: It was an online survey of 137 psychiatrists in 18 countries including both high and low economies, using a pre-designed questionnaire; with both quantitative and qualitative measures. Results: Antidepressant prescribing appeared close to the evidence-based guidelines. There was frequent use of other medications alongside antidepressants since treatment initiation. There were many challenges in managing depression, such as treatment non-response, resistance, and discontinuation; side effects, mostly sexual problems; inadequate psychological intervention; availability and affordability of treatment modalities; comorbidities, especially substance use and personality disorders; stigma; and lack of education and training. Suggested approaches for solutions included personalized treatment, quicker follow-up, psychoeducation, blending psychological intervention into routine clinical practice, improving continuity of care, and preventing treatment discontinuation. Support from governments for improving access, making interventions affordable, and providing socio-occupational support is essential. Training and development of professionals, public education providing information, and dealing with stigma are still relevant. Conclusions: The results indicated a need for reviewing current practices in managing depression, optimizing it with available resources, and preventing treatment discontinuation, and non-response. Making treatment available and affordable, public education fighting stigma to improve treatment acceptability, and research addressing gaps in interventions, especially for treatment resistance and psychotherapy are other approaches that may improve depression management.

1. Introduction

Depressive disorders are a major public health concern worldwide. These are highly prevalent in the general population and in both primary and secondary care settings. Globally, an estimated 3.8% of the population suffers from depression, which includes 5% of adults and 5.7% of older adults above 60 years [1]. Among the mental illnesses, depression accounts for the largest proportion of disability-adjusted life-years (DALYs) [2]. A study in 18 countries suggested an average lifetime (14.6%) and 12-month (5.5%) prevalence of major depressive episodes in 10 high-income countries (HIC), compared to 11.1% and 5.9%, respectively, in eight low-income countries [3].
It appears as if the depression prevalence is increasing over the years and during stressful situations; e.g., in the UK, it was 5% in the general population in 1994 [4], 7.5% in 2014 [5], which increased to 32% during the COVID-19 pandemic which was a 27.9% increase from the pre-pandemic 4.1% [6]. Globally, there was an increase of 27.6% in cases of major depressive disorder during the COVID pandemic [7].
Depression is common in primary care with reported prevalence rates around 4% to 16% [8,9,10], and most of the depressed patients are treated there. Reported proportions of patients with depression in psychiatric outpatients vary, and have been reported from 19.3% [11] to 54.4% [12]. Rates of up to 55.2% in general hospital outpatient departments have been reported [13]. In general hospital inpatient settings involving medicine and surgery departments, the prevalence of major depression has been reported to be between 5% to 34% [14,15], suggesting that this is a widespread condition. When depression and depressive symptoms are taken together, the prevalence figures in different specialties vary from 17% to 53% [16]. Besides clinical settings, depression is common in educational [17,18,19,20], and occupational environments [21], and is a major reason for impairment in functioning. This is associated with poorer scholastic achievement and is a leading cause of sickness absences.
Depression is commonly associated with physical illnesses as a comorbid condition. Many physical illnesses are etiologically linked with depression. Commonly associated physical illnesses with depression are diabetes, thyroid disorders, adrenal disorders, hypercalcemia, hyponatremia, cerebrovascular accident, multiple sclerosis, subdural hematoma, epilepsy, Parkinson’s disease, Alzheimer’s disease, malignancies, infectious diseases such as HIV and syphilis, nutritional deficiencies such as vitamin D, B12, B6 deficiency, iron or folate deficiency, etc. Depression is also associated with medication or substances of abuse such as steroids, antihypertensives, anticonvulsants, antibiotics, sedatives, hypnotics, alcohol, stimulant withdrawal, etc. [22].
Patients with depression are hospitalized mostly for physical illnesses such as endocrine, musculoskeletal, and vascular diseases, rather than psychiatric disorders [23]. Depression increases the risk of treatment noncompliance for physical illnesses by three times [24,25]. The association of depression with physical illnesses increases the burden, functional impairment, health service utilization, non-psychiatric hospital admission, cost of care; worsens prognosis, and increases mortality [26,27]. This highlights that identification and treatment of depression should be a priority in both primary and secondary care [23,28]. As evident, depressive disorders and these conditions are prevalent in primary, secondary, and tertiary medical care settings and contribute to suffering as a comorbid condition and worsen the prognosis of associated illnesses [23,29]. Despite these concerns, there is a chance that in primary and secondary care settings, depression is missed as a diagnosis or is not adequately treated [28,30].
Besides single and recurrent major depressive episodes, there are various other kinds of depression such as persistent depressive disorder (dysthymia), mixed depressive and anxiety disorder, disruptive mood dysregulation disorder in children and adolescents, premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, and unspecified depressive disorder [31,32]. Besides physical comorbidities, psychiatric comorbidities are common in depressive disorders, such as alcohol and other substance use disorders, anxiety disorder, panic disorder, social anxiety disorder, obsessive-compulsive disorder, personality disorders, etc. [33].
It is known that untreated depression may continue for around 6–12 months; a good proportion of these become recurrent and chronic. Suicidal attempts and death are commonly linked to depression [34], and there is usually an eight-fold increase in suicide [33], while 2/3rd contemplate suicide and 10–15% die by suicide. Comorbidities increase the risk of suicide [33]. Besides suicidal death, all-cause mortality is higher in depressed patients as well [33].
Management approaches for depression involve psychotherapies, antidepressants, adjuncts or augmenting drugs, electroconvulsive therapy (ECT), other neuromodulation, and lifestyle modifications. Antidepressants have a robust evidence base for their effectiveness. In primary care, the numbers needed to treat (NNT) for tricyclic antidepressants range from 7 to 16 (median 9) and for selective serotonin reuptake inhibitors (SSRI) from 7 to 8 (median 7) [35]. Among the SSRIs, sertraline has been reported to be significantly better in efficacy and acceptability [36]. Combined treatment with psychotherapy improves efficacy with clinically meaningful outcomes [37].
Despite massive prevalence, pervasive presence in various settings, being present as a common comorbid condition of many physical illnesses, and relative ease in identifying symptoms and making a diagnosis, it is common to see that depression is missed in various clinical settings such as primary care even in HIC [38,39,40], LAMIC [30], emergency departments, and secondary care [41].
In addition, although there are many available treatment options, a considerable proportion of patients with depression are not treated, more so in LAMIC [42]; for example, more than 75% of people in LAMIC receive no treatment [1,43]. Among those who are treated, a proportion of them do not receive adequate treatment and there is less than adequate response to treatment. Despite the evidence base of efficacious interventions, only 18% of patients experience a 50% or greater decrease in symptoms after 6 months [33]. Inadequate or non-response is common in depression and that adds a huge clinical, psychosocial, and occupational burden. In fact, depression remains one of the leading causes of disease burden worldwide [44]. There are many surveys involving patients [45], and a few surveys in the past involving clinicians, but these were limited to regions or topics such as treatment-resistant depression (TRD) [46], and ECT [47], rather than a comprehensive view.
There is hardly any study that looks at the views of psychiatrists globally about issues such as poor recognition, missed diagnoses, inadequate treatment, and responses to depression at the ground level. Clinicians experience hurdles first-hand and can provide valuable input about the reasons. In this context, it was intended to explore the challenges clinicians face while managing depression in their clinical practice and their suggestions for solutions.

2. Results

There were 137 respondents from 18 countries: 70 (51.1%) from HIC and 67 (48.9%) from low and middle-income countries (LAMIC). Most of them (99, 72.3%) were in public (government, university, etc.), 34 (24.8%) in private hospital setups, and 4 (2.9%) in others. More LAMIC respondents were in private organizations (35.8% vs. 14.3%) and fewer in the public sector (62.7% vs. 81.4%) compared to HIC (p < 0.05). Most of the respondents (98, 71.5%) were from teaching organizations. There were 57.7% consultant psychiatrists including professors, 21.9% psychiatrists (senior residents, associate specialists, etc.), 14.6% psychiatry trainees, and 5.8% doctors who were not in psychiatry but managed psychiatric patients; with 35.8% having 0–9 years of clinical psychiatry experience, 24.1% with 10–19 years and 40.1% had 20 or more years.

2.1. Common Challenges in Managing Depression

At the beginning of the survey, the most common challenges faced by psychiatrists in their clinical practice managing depression were enquired about. The responses were analyzed qualitatively and provided below as major themes and subthemes (Table 1).

2.2. Identification of Depression

Regarding depression being identified by primary or secondary care physicians or by significant others, 13.9% of respondents were not at all confident, 58.4% were somewhat confident, and only around a quarter (27.7%) were confident. There was a significant difference among respondents from LAMIC reporting no confidence (23.9% vs. 4.3%) compared to those from HIC (p < 0.005).

2.3. Unmet Needs of Psychological Intervention

The majority of the respondents (65.7%) reported having facilities for psychological intervention, 7.3% did not, and 27.0% had limited facilities (NS). Considering the availability of specific psychotherapies, the responses were: cognitive-behavioral therapy (CBT) (93.4%), problem-solving therapy, (43.8%), behavioral activation, (38.7%), interpersonal therapy (IPT) (38.0%), mindfulness-based psychotherapy (37.2%), brief psychodynamic therapy (18.2%), and other (6.6%). A higher proportion of respondents from LAMIC reported having the availability of IPT (43.3% vs. 32.9%), behavioral activation (50.7% vs. 27.1%), and problem-solving therapy (59.7% vs. 28.6%) compared with HIC, whereas CBT was more available in HIC (98.6% vs. 88.1%). In clinical practice, the most common challenges related to psychotherapy reported by the respondents were availability (62.8%), long waiting lists (56.2%), accessibility (45.3%), and affordability (30.7%).

2.4. Antidepressant Medications

The specific antidepressant prescribed as the first choice was sertraline (51.1%); however, it was more (64.3%) in HIC, compared to LAMIC (37.3%) where the first choice was escitalopram (47.8%). The first choice for the second-line antidepressant was venlafaxine including desvenlafaxine (32.1%) (HIC: 34.3%, vs. LAMIC: 29.9%), followed by mirtazapine 22.6% (HIC: 25.7%, LAMIC: 19.4%).
Based on the overall responses involving three choices, the ranks of first-line antidepressants were sertraline (75.2%), fluoxetine (44.5%), escitalopram (43.8%), mirtazapine (21.2%), venlafaxine (18.2%), citalopram (13.1%), and desvenlafaxine (5.1%). Similarly, overall ranks of second-line antidepressants were mirtazapine (49.6%), venlafaxine (42.3%), duloxetine (14.6%), bupropion (11.7%), amitriptyline (10.9%), desvenlafaxine (9.5%), vortioxetine (8.8%), fluoxetine (8.0%), escitalopram (5.8%), paroxetine (5.8%), and sertraline (5.1%).

2.5. Medications Prescribed Alongside Antidepressants

While initiating antidepressant drugs, respondents reported prescribing benzodiazepines (40.5%), second-generation antipsychotic drugs (13.7%), anxiolytics (29.0%), and no other medication only in 16.8% (131 responses). There was a significant difference in LAMIC where 53.8% use benzodiazepines in contrast to 27.3% in HIC, and no additional medication in 6.2% vs. 27.3%, respectively (p < 0.005).

2.6. Augmenting Agents

Considering augmenting agents, lithium (17.5%) was the first choice followed by olanzapine (11.7%), quetiapine (10.2%), aripiprazole (8.8%), and mirtazapine (8.0%). However, considering all three choices provided, the order of preference for the commonly prescribed augmenting agents was: lithium (36.5%), quetiapine (28.5%), olanzapine (23.4%), aripiprazole (19.7%), mirtazapine (11.7%), and lamotrigine (7.3%).

2.7. Type of Depression

The survey specifically enquired regarding management strategies for TRD and bipolar depression. The average percentage of patients who were perceived to have TRD by the respondents (132 responses) was 21.0 ± 14.6 (median 20) with no significant difference between HIC (20.8 ± 15.5) and LAMIC (21.2 ± 13.8). Common treatment strategies in managing TRD used by the respondents are given in Table 2. There was no response for vagus nerve stimulation (VNS) and only one response for transcranial direct current stimulation (tDCS) from LAMIC. Common strategies for managing bipolar depression in clinical practice are given in Table 3.

2.8. Common Reasons for Treatment Discontinuation

Considering the reasons for patients discontinuing medications, it was observed that the most common first responses were impaired insight (43.1%) and side effects (40.1%). However, considering all the responses, the overall ranks were side effects (73.0%), lack of response to treatment (53.3%), impaired insight (46.7%), lack of psychoeducation (46.7%, stigma (35.8%), and the inability to afford treatment (27.0%). Side effects posing a challenge to treatment adherence are given in Table 4. Among the sexual problems, 36.5% did not specify the nature of the problem, except that decreased libido (5.1%) and erectile dysfunctions (4.4%) were specifically mentioned in a few. Challenges for continuity of care are summarized in Table 5.

2.9. Continuity of Care Issues

A review of the patients after the initial assessment was conducted within less than a month in 43.1%, within one to two months in 49.6%, and in more than two months (7.3%). Although more than half (57.7%) of the respondents reported no problem in arranging laboratory investigations (to rule out organic causes or monitoring, e.g., lithium) for the treatment, 21.2% reported definite challenges, and another 21.2% faced their challenges to an extent. The challenges in continuing the care are mentioned in Table 5.

2.10. Treatment Availability

Interestingly, almost half (46.7%) of the respondents from both HIC (41.4%) and LAMIC (52.2%) reported that they were not able to prescribe treatment as it was not available or was difficult to procure (NS); it was mostly rTMS (18.2%). There are availability issues in organizational formulary (6.6%) or government pharmacy (5.1%) for the medications. Most respondents (73.7%) reported access to electroconvulsive therapy (ECT), and repetitive transcranial magnetic stimulation (rTMS) (20.4%). However, 23.4% had no access to ECT, rTMS, or VNS. In the previous year, 59.1% of respondents had used ECT, 16.1% rTMS, 1.5% VNS, and 35.8% had used none.

2.11. Treatment Cost

Most respondents (64.2%) from LAMIC in contrast to 24.3% of HIC reported that patients face a challenge regarding the affordability of the treatment cost of depression (p < 0.001). More than half the patients (57.4%) receive the treatment for free, according to respondents; however, it was 70.0% for HIC and 43.9% for LAMIC. In addition, 40.9% of respondents from LAMIC reported that patients bear all the treatment costs in contrast to 5.7% from HIC (p < 0.001). In a minority (13.2%) of cases, patients bear part of the costs and in 2.9% insurance pays in full and in 3.7% insurance pays in part.

2.12. Suggestions for Solutions

At the end of the survey, suggestions were invited regarding solutions for all the challenges of managing depression. The suggestions are summarized in Table 6.

3. Discussion

This survey of psychiatrists was about the challenges they face in managing depression in clinical practice. The sample was spread across various grades in different work settings from government, academic, and private sectors in HIC and LAMIC. Major themes about the challenges of managing depression, ground realities observed, and the solutions suggested by the psychiatrists on the clinical frontline are discussed below.

3.1. Identifying Depression

It is evident from the responses that psychiatrists are not confident that depression is being identified by primary or secondary care clinicians, which suggests improving the education and training on mental illness for other professionals, e.g., for medical and nursing students, general practitioners (GPs), and other doctors in secondary care. It is probably better to arrange the training periodically as most clinicians do not undergo any training following their graduation.
The possibility of depression can be suspected by clinical judgment, or positive answers to either screening questions such as ‘often being bothered by feeling down, depressed, or hopeless’ and ‘having little interest or pleasure in doing things during the last month’ [48,49]. Similarly, screening with the first two items of the Patient Health Questionnaire (PHQ)-9 (termed the PHQ-2) [50], and a score of two or higher has 86% sensitivity and 78% specificity for diagnosing major depression which is 74% and 91%, respectively, for a score of 10 on the PHQ-9 [51]. Diagnostic criteria provided by the classificatory systems help diagnose depression by primary care clinicians [31,32,52] who can easily ascertain the somatic symptoms and syndrome associated with depression [53]. In addition, there are many commonly used patient-rated scales e.g., Beck Depression Inventory [54], Zung Self-Rating Depression Scale [55], etc., or clinician-rated scales, e.g., Hamilton’s Rating Scale for Depression [56], and Montgomery-Asberg Depression Rating Scale [57], etc., to identify and grade the severity of depression.
Mild depression can be managed in primary care [49], and there is a need to identify and manage depression associated with physical illnesses in both primary and secondary care [58]. Along with clinical settings, it is essential to improve the identification of depression in the general public, educational (schools and colleges), and work environments. Specific information about identifying signs and symptoms, and supportive measures to the public, teachers, and managers may be helpful.

3.2. Medicinal Treatment

Results from this survey indicated that while a wide range of antidepressants is considered in clinical practice, SSRIs are commonly considered as the first-line treatment as most guidelines suggest. In the second-line, mirtazapine and venlafaxine are considered mostly. A huge proportion of patients (83.2%) are prescribed additional medications while starting antidepressants reflecting the current practice to deal with associated symptoms, mostly benzodiazepines, second-generation antipsychotic drugs, and anxiolytics. This area needs further research, as even the combination of antidepressant and antipsychotic drugs for psychotic depression is under-studied [59]. It was observed that lithium was still the first choice as an augmenting agent, followed by second-generation antipsychotics (SGA). There is a suggestion for combining two antidepressants in this regard, and mirtazapine was used this way by many.

3.3. Availability of Treatment Modalities

Many respondents from both HIC and LAMIC reported the issue of the availability of drugs. Besides availability on the market, some of the medications are not available in government pharmacies in LAMIC that provide them free to patients. In HIC, some of the medications are not available in hospital pharmacies for various reasons, including cost, supportive guidelines, etc. The non-availability may indirectly impact patient care limiting the resources of the clinicians. Interestingly, many respondents (46.7%) reported that they were not able to prescribe treatment as it was not available or difficult to procure; however, these included mostly rTMS, medications in hospital or government pharmacies, or periodic shortages.

3.4. Challenges in Continuity of Care

The psychiatrists reported many challenges during the follow-up of patients; major issues observed were non-adherence to treatment, missed appointments, comorbid personality disorders, substance use, other psychiatric disorders, and unmet psychological needs. All these impact the continuity of care, and outcome.
Less than half of the patients could be seen within one month of treatment initiation; however, most were seen within two months. In minority patients (7.3%), the medication review happened more than two months after the initiation of treatment; this might affect the timely dose optimization, which may secondarily impact response, perception of non-effectiveness of medications, and discontinuation/non-adherence. Being in contact in person or over the phone/online might help, where access, travel, and cost impact the follow-up visits. Facilities for earlier follow-ups may help in identifying early signs of non-response and optimizing treatment.

3.5. Treatment Non-Adherence

Medication non-adherence is common in patients with depression [60]. Various reasons were reported for treatment non-adherence; besides side effects, lack of response to treatment, impaired insight, and lack of psychoeducation were cited as major causes. Stigma and affordability were other reasons. Most of these reasons can be addressed satisfactorily, some through treatment approaches, others through patient and public education. Psychoeducation of the patients addressing their possible reasons for non-adherence and the risks associated is recommended [61].

3.6. Side Effects Leading to Discontinuation

As observed, side effects were the most common (73.0%) reason for the discontinuation of medications. Among them, sexual side effects were most frequently cited. There is a need to manage this side effect, through proactive assessment, counseling, and the use of appropriate medicinal strategies including antidepressants [62,63]. Other commonly reported side effects were weight gain, sedation, gastrointestinal problems, and agitation, which need to be addressed as well. It was interesting to note that sedation was reported more than twice as frequently in LAMIC, as a cause of discontinuation, where benzodiazepines were prescribed almost twice as frequently which was significant. Medications prescribed alongside antidepressants need to be reviewed periodically for their role and side effects. Specific guidelines and training about managing these side effects, making them a priority focus during clinical reviews is essential. Improving adherence to medications might be able to deal with many pseudo-non-responses to treatment [64].

3.7. Challenges of Managing TRD

In this study, the average proportion of patients considered by the respondents as TRD was 21% which is lower than many reported rates. The proportion of patients with TRD is usually considered to be at least 30% [60,61]. However, many patients considered to have TRD could be pseudo-resistant due to the inadequacy of treatment trials or non-adherence to treatment [64]. Nonetheless, there is a possibility that respondents may be underestimating the proportion of patients with TRD in their clinical settings. The respondents reported various strategies to manage TRD, most of which are well known; although the evidence regarding extending antidepressant trials, medication switching, and combining antidepressants has been reported to be mixed for TRD [64]. The reported strategies of managing depression appeared similar in the initial steps of starting with an SSRI and switching to another SSRI or venlafaxine, or augmenting with thyroid hormone, but the approaches of using bupropion, buspirone, and tranylcypromine as used in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial [65], were not reported.
Some second-generation antipsychotics (e.g., aripiprazole, brexpiprazole, cariprazine, quetiapine XR) are proven effective as adjunctive treatments to antidepressants in partial responders, but only the olanzapine-fluoxetine combination has been studied in FDA-defined TRD [64]. Similarly, while the role of ECT is fairly established; evidence is becoming more robust for rTMS which is reported to be as effective [64]. Intravenous ketamine and intranasal esketamine (co-administered with an antidepressant) are established as efficacious, and around 19% of respondents mentioned this.
The availability of ECT and neuromodulation was not uniform, based on the results. Around a quarter (26.9%) of respondents reported no access to ECT in their clinical practice; while the rest had only 59.1% used ECT in the previous year. ECT is regarded as an effective acute and maintenance intervention in TRD [65]; however, it appears it is underused. Access to rTMS was present for 20.4%, and its role in TRD has been established as an adjunct [66].
Most of the approaches to managing TRD in HIC and LAMIC were comparable. However, there were minor variations, such that lithium, ECT, thyroid hormone, intranasal esketamine, and bupropion were reported to be more frequently used by the respondents from LAMIC, whereas switching antidepressants was more frequently reported by the psychiatrists in HIC. It is difficult to reflect on the possible reasons for this variation; however, a few generalizations may be suggested. It has been reported that ECT use is decreasing in many HIC [67]. The cost of treatment for depression is possibly one of the limiting factors impacting treatment choice for a proportion of patients in LAMIC [68,69]; however, comparatively more patients there received additional medications alongside antidepressants. Identifying TRD early and following evidence-based approaches available might be helpful.

3.8. Challenges of Managing Bipolar Depression

Common approaches to managing bipolar depression observed in this survey were similar to the guidelines, in certain aspects. Interestingly, some respondents used two mood stabilizers (19.7%) and considered no antidepressant (16.1%) while managing bipolar depression. The suggestions from NICE guidelines in the UK include CBT, IPT, behavioral couples therapy, fluoxetine-olanzapine combination, or quetiapine, and if there is no response to consider lamotrigine. It advocates optimizing the dose of lithium or valproate if the patient is already on them and adding other medications [70]. A few SGAs (quetiapine, lurasidone, cariprazine, lumateperone, and olanzapine with fluoxetine) are effective and approved by the FDA for bipolar depression [71]. Around one-third of respondents reported psychotherapy as one of the treatment modalities for bipolar depression. There are many suggestions for effective psychotherapies for bipolar depression, such as CBT, IPT, family-focused treatment, and social rhythm therapy [72], including dialectical behavior therapy, mindfulness-based therapy, and psychoeducation [73]; however, the quality of evidence needs to be viewed with caution [74]. As observed in the study, challenges in managing bipolar depression remain and require further study in different resource-scarce areas.

3.9. Depression with Comorbidities

Another area of challenges reported by the psychiatrists was managing comorbidities, primarily personality disorders and substance use disorders, which are commonly associated [33]. They are known to affect the outcome of depressive disorder, complicating the progress. Most of the time, these comorbidities are not addressed because of a lack of intervention facilities, and these pose a challenge during follow-ups. Strategies and resources for managing these comorbidities are vital to achieving remission in depressive disorders.

3.10. Psychological Intervention

It was a concern to observe that the continuity of care was impacted in a huge proportion of cases, for unresolved psychological stress issues, more frequently in LAMIC (Table 5). Similarly, patients with personality disorders and substance use had challenges during follow-up. These would need psychological interventions.
Major themes related to psychotherapy for depression across the HIC and LAMIC were accessibility and affordability of psychotherapy, and where it is available, there is a long waiting list. While there are many psychotherapy approaches such as counseling, CBT, IPT, behavioral activation, problem-solving therapy, brief psychodynamic therapy, mindfulness-based psychotherapy, etc., with higher efficacy compared to the usual care [33] often these are not available or not affordable. Improving the availability of psychological intervention is a foregone conclusion.
Besides increasing the workforce and making services available nearer to patients and more affordable, there are few other options. Using technologies such as internet-based therapy, therapy over the phone and video, etc., are already in place, effective, and can be easily adapted to different settings [75,76]. Psychotherapies can be blended into the circumstances improving their use. Short-duration psychotherapies can be easily provided in the usual clinical setup where resources for psychological intervention are scarce. There are examples of techniques with less therapist time being non-inferior to standard CBT [77], fewer sessions of CBT [78], and brief interventions that can be delivered during outpatient visits [79].
Various measures of psychological intervention can be included in routine clinical practices such as psychoeducation. Psychoeducation has been reported to be effective in improving the clinical course, treatment adherence, and psychosocial functioning of depressive patients [80]. Family psychoeducation has been noted to have a small but significant effect on depression in the short and long term [81]. It also helps in the prevention of depression, more so in children, adolescents, and younger adults [82]. Similarly, problem-solving therapy and behavioral activation can be a part of usual clinical intervention [49]. In resource-scarce areas, and with large patient populations, group therapies may be a better option than individual one-to-one sessions. In addition, guided self-help, lifestyle advice [83,84], and exercise [85], can be routine parts of clinical management.

3.11. Affordability of the Treatment Cost

Depression has a high economic burden not only on patients and families but also on nations due to clinical and work-related costs [86,87]. A little over half of the patients with depression receive the treatment free; however, a higher proportion of patients in HIC receive it free compared to LAMIC and a significantly higher proportion of patients or their families in LAMIC bear the total cost of care. This might indirectly influence the adherence and continuity of treatment for a proportion of patients. One of the ways of managing a huge number of patients with depression is supporting more tele-mental-health service facilities, with assessment, prescriptions, psychotherapy, follow-ups, and even emergency contact. These may improve access to treatment. The cost of care may be decreased through government planning, monitoring the cost of medications and other treatment modalities, and appropriate resource allocation prioritizing the treatment of depression.

3.12. Managing Stigma

Another major theme that contributed to seeking and continuing treatment was stigma. It is common worldwide and impacts help-seeking as a barrier [88]. Along with the patients, education for family members and the general public is consistently needed. While mental health professionals may lead this process, it is essential that health, social welfare, media, and governmental agencies play their roles effectively. This aspect needs to be particularly prioritized and addressed during clinical reviews.

3.13. Limitations

There are several limitations to this study. The sample size is relatively small and the coverage of countries is limited. The findings are the observational accounts of the practicing clinicians, rather than clinical data from patients, although this was the focus of the study to explore the challenges faced by psychiatrists in managing depression. However, the views of patients, their caregivers, and the health authorities may be different. Any confounding factors influencing the responses from the participants are not known. There may be variations within HIC and LAMIC regarding the scope and availability of mental health service facilities which were not specifically studied.

4. Materials and Methods

4.1. Setting

It was an online survey based on a pre-designed questionnaire.

4.2. Participants

Participants included psychiatrists and other doctors who were managing psychiatric patients, and working in various clinical settings such as government hospitals, private setups, and teaching or non-teaching organizations.

4.3. Recruitment

The online link and information about the survey were circulated in different countries by colleagues supporting the project, in September 2024, among participants with a request to share the link with interested colleagues. Two reminders were given to participants to complete the survey.

4.4. Questionnaire

The questionnaire asked for the most common challenge clinicians face in managing depression in their clinical practice. Other specific questions included were: the confidence level of respondents about depression being identified in primary and secondary care, facility for psychological intervention, commonly available psychotherapies, challenges related to psychological interventions, first and second-line antidepressants, common additional medications, augmenting drugs, strategies for treating TRD, bipolar depression, common reasons for discontinuation of treatment by the patients, side effects affecting adherence, affordability of treatment cost and its provider. Challenges the clinicians encountered in arranging laboratory investigations, follow-up appointments, and access to ECT and other neuromodulation, were checked. Suggestions for the solutions to the challenges in managing depression were also enquired about. The questionnaire needed around 10–12 min to complete.

4.5. Ethical Aspects

Information about the survey was provided to participants on the online link, and consent was taken electronically. The respondents had the option not to participate, terminate their participation at any point, and not submit the form. It was an anonymous survey; no identifiable details of the respondents were collected. All the data was confidential. There was an option to contact the research team for any further information about the survey.

4.6. Analysis

The quantitative data were analyzed using SPSS version 28.0 (Armonk, NY, USA: IBM Corp). Missing data were not included in the analysis. The themes and subthemes were derived from the qualitative information in response to the open-ended questions.

5. Conclusions

The responses from psychiatrists highlighted that there are many challenges in managing depression which can be summarized as treatment non-response, resistance, discontinuation, side effects mostly sexual in nature, inadequate psychological intervention, unavailability and unaffordability of treatment, comorbidities, especially substance use and personality disorders, stigma, and lack of education and training. Changing approaches to intervention, e.g., personalized treatment; quicker follow-up, psychoeducation, blending psychological intervention into routine clinical practice, and efforts to prevent treatment discontinuation to improve continuity of care might help. Policy support from governments, improving accessibility and affordability of treatment, and providing socio-occupational support for the patients appear essential. Training of professionals especially those who are not in psychiatry, public education about depression, treatment effectiveness, and management of stigma are needed.
This survey highlighted a few areas that may be a focus of further research, such as methods of providing psychological interventions for large patient populations, especially in resource-scarce situations, evaluating the effectiveness of fewer and shorter therapy sessions, culturally adapted therapies, management of depression with multiple comorbidities, and methods that can improve the long-term outcome of depression, decreasing non-response or resistance. These might help update the currently available guidelines for clinicians.

Funding

This research received no external funding.

Institutional Review Board Statement

The project was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Committee of the Quality of Life Research and Development Foundation, 2024/8/CDCP, dated 24 February 2024, as a Service Evaluation.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the author upon reasonable request.

Acknowledgments

Raghavakurup Radhakrishnan, New Zealand; Jayashree Viswanathan, Australia; Sujita Kumar Kar, India; S M Yasir Arafat, Bangladesh, Prasant Mohapatra, India, Indika Krishangani, Srilanka; Subas Pradhan, UK; Maju Mathew Koola, USA; Shishir Regmi, New Zealand supported data collection. Shreyan Kar, UK helped in data management. The Institute of Insight, United Kingdom, and Quality of Life Research and Development Foundation (QoLReF), India provided administrative and technical support. During the preparation of this work the author used ChatGPT (version GPT-4) in order to analyze theme and subthemes. After using this tool/service, the author reviewed and edited the content as needed and takes full responsibility for the content of the publication.

Conflicts of Interest

The author declares no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
CBTCognitive-behavioral therapy
COVIDCoronavirus disease
ECTElectroconvulsive therapy
HICHigh-income countries
IPTInterpersonal therapy
LAMICLow and middle-income countries
NNTNumbers needed to treat
PHQPatient health questionnaire
rTMSRepetitive transcranial magnetic stimulation
SSRISelective serotonin reuptake inhibitors
tDCSTranscranial direct current stimulation
TRDTreatment-resistant depression
VNSVagus nerve stimulation

References

  1. World Health Organization Depressive Disorder (Depression). Available online: https://www.who.int/news-room/fact-sheets/detail/depression (accessed on 23 October 2024).
  2. GBD 2019 Mental Disorders Collaborators. Global, Regional, and National Burden of 12 Mental Disorders in 204 Countries and Territories, 1990–2019: A Systematic Analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry 2022, 9, 137. [Google Scholar] [CrossRef] [PubMed]
  3. Bromet, E.; Andrade, L.H.; Hwang, I.; Sampson, N.A.; Alonso, J.; de Girolamo, G.; de Graaf, R.; Demyttenaere, K.; Hu, C.; Iwata, N.; et al. Cross-National Epidemiology of DSM-IV Major Depressive Episode. BMC Med. 2011, 9, 90. [Google Scholar] [CrossRef] [PubMed]
  4. Ohayon, M.M.; Priest, R.G.; Guilleminault, C.; Caulet, M. The Prevalence of Depressive Disorders in the United Kingdom. Biol. Psychiatry 1999, 45, 300–307. [Google Scholar] [CrossRef] [PubMed]
  5. Arias de la Torre, J.; Vilagut, G.; Ronaldson, A.; Dregan, A.; Ricci-Cabello, I.; Hatch, S.L.; Serrano-Blanco, A.; Valderas, J.M.; Hotopf, M.; Alonso, J. Prevalence and Age Patterns of Depression in the United Kingdom. A Population-Based Study. J. Affect. Disord. 2021, 279, 164–172. [Google Scholar] [CrossRef]
  6. Dettmann, L.M.; Adams, S.; Taylor, G. Investigating the Prevalence of Anxiety and Depression during the First COVID-19 Lockdown in the United Kingdom: Systematic Review and Meta-Analyses. Br. J. Clin. Psychol. 2022, 61, 757–780. [Google Scholar] [CrossRef]
  7. Santomauro, D.F.; Mantilla Herrera, A.M.; Shadid, J.; Zheng, P.; Ashbaugh, C.; Pigott, D.M.; Abbafati, C.; Adolph, C.; Amlag, J.O.; Aravkin, A.Y.; et al. Global Prevalence and Burden of Depressive and Anxiety Disorders in 204 Countries and Territories in 2020 Due to the COVID-19 Pandemic. Lancet 2021, 398, 1700–1712. [Google Scholar] [CrossRef]
  8. Akincigil, A.; Matthews, E.B. National Rates and Patterns of Depression Screening in Primary Care: Results from 2012 and 2013. Psychiatr. Serv. 2017, 68, 660–666. [Google Scholar] [CrossRef]
  9. Craven, M.A.; Bland, R. Depression in Primary Care: Current and Future Challenges. Can. J. Psychiatry Rev. Can. Psychiatr. 2013, 58, 442–448. [Google Scholar] [CrossRef]
  10. Yen Phi, H.N.; Quoc Tho, T.; Xuan Manh, B.; Anh Ngoc, T.; Minh Chau, P.T.; Trung Nghia, N.; Nghia, T.T.; Ngoc Quynh, H.H.; Huy, N.T.; Linh, N.T.; et al. Prevalence of Depressive Disorders in a Primary Care Setting in Ho Chi Minh City, Vietnam: A Cross-Sectional Epidemiological Study. Int. J. Psychiatry Med. 2023, 58, 86–101. [Google Scholar] [CrossRef]
  11. Abumadini, M.S. Depressive Disorders in Psychiatric Outpatient Clinic Attendees in Eastern Saudi Arabia. J. Fam. Community Med. 2003, 10, 43. [Google Scholar] [CrossRef]
  12. Mitchell, A.J.; McGlinchey, J.B.; Young, D.; Chelminski, I.; Zimmerman, M. Accuracy of Specific Symptoms in the Diagnosis of Major Depressive Disorder in Psychiatric Out-Patients: Data from the MIDAS Project. Psychol. Med. 2009, 39, 1107–1116. [Google Scholar] [CrossRef] [PubMed]
  13. Ali, M.; Jama, J.A. Depression among General Outpatient Department Attendees in Selected Hospitals in Somalia: Magnitude and Associated Factors. BMC Psychiatry 2024, 24, 579. [Google Scholar] [CrossRef] [PubMed]
  14. van Niekerk, M.; Walker, J.; Hobbs, H.; Magill, N.; Toynbee, M.; Steward, B.; Harriss, E.; Sharpe, M. The Prevalence of Psychiatric Disorders in General Hospital Inpatients: A Systematic Umbrella Review. J. Acad. Consult. Liaison Psychiatry 2022, 63, 567–578. [Google Scholar] [CrossRef] [PubMed]
  15. Walker, J.; Burke, K.; Wanat, M.; Fisher, R.; Fielding, J.; Mulick, A.; Puntis, S.; Sharpe, J.; Esposti, M.D.; Harriss, E.; et al. The Prevalence of Depression in General Hospital Inpatients: A Systematic Review and Meta-Analysis of Interview-Based Studies. Psychol. Med. 2018, 48, 2285–2298. [Google Scholar] [CrossRef]
  16. Wang, J.; Wu, X.; Lai, W.; Long, E.; Zhang, X.; Li, W.; Zhu, Y.; Chen, C.; Zhong, X.; Liu, Z.; et al. Prevalence of Depression and Depressive Symptoms among Outpatients: A Systematic Review and Meta-Analysis. BMJ Open 2017, 7, e017173. [Google Scholar] [CrossRef]
  17. Puthran, R.; Zhang, M.W.B.; Tam, W.W.; Ho, R.C. Prevalence of Depression amongst Medical Students: A Meta-Analysis. Med. Educ. 2016, 50, 456–468. [Google Scholar] [CrossRef]
  18. Li, W.; Zhao, Z.; Chen, D.; Peng, Y.; Lu, Z. Prevalence and Associated Factors of Depression and Anxiety Symptoms among College Students: A Systematic Review and Meta-Analysis. J. Child Psychol. Psychiatry 2022, 63, 1222–1230. [Google Scholar] [CrossRef]
  19. Rath, N.; Kar, S.; Kar, N. Mental Health in the University Campus: Emphasizing the Need for Preventive Health Actions. Indian J. Soc. Psychiatry 2021, 37, 225–229. [Google Scholar] [CrossRef]
  20. Kar, N.; Das, M.; Kar, B.; Rath, N.; Kar, S. Dimensional Distribution of Anxiety and Depression in College Students in a Rural Setting: Relationship with Stress, Well-Being, and Quality of Life. Indian J. Soc. Psychiatry 2024, 40, 411–417. [Google Scholar] [CrossRef]
  21. Amiri, S. Prevalence of Depression Disorder in Industrial Workers: A Meta-Analysis. Int. J. Occup. Saf. Ergon. JOSE 2022, 28, 1624–1635. [Google Scholar] [CrossRef]
  22. Bains, N.; Abdijadid, S. Major Depressive Disorder. In StatPearls; StatPearls Publishing: Treasure Island, FL, USA, 2024. [Google Scholar]
  23. Frank, P.; Batty, G.D.; Pentti, J.; Jokela, M.; Poole, L.; Ervasti, J.; Vahtera, J.; Lewis, G.; Steptoe, A.; Kivimäki, M. Association Between Depression and Physical Conditions Requiring Hospitalization. JAMA Psychiatry 2023, 80, 690–699. [Google Scholar] [CrossRef] [PubMed]
  24. DiMatteo, M.R.; Lepper, H.S.; Croghan, T.W. Depression Is a Risk Factor for Noncompliance with Medical Treatment: Meta-Analysis of the Effects of Anxiety and Depression on Patient Adherence. Arch. Intern. Med. 2000, 160, 2101–2107. [Google Scholar] [CrossRef] [PubMed]
  25. Poletti, V.; Pagnini, F.; Banfi, P.; Volpato, E. The Role of Depression on Treatment Adherence in Patients with Heart Failure—A Systematic Review of the Literature. Curr. Cardiol. Rep. 2022, 24, 1995. [Google Scholar] [CrossRef]
  26. Katon, W.J. Epidemiology and Treatment of Depression in Patients with Chronic Medical Illness. Dialogues Clin. Neurosci. 2011, 13, 7. [Google Scholar] [CrossRef]
  27. Prina, A.M.; Cosco, T.D.; Dening, T.; Beekman, A.; Brayne, C.; Huisman, M. The Association between Depressive Symptoms in the Community, Non-Psychiatric Hospital Admission and Hospital Outcomes: A Systematic Review. J. Psychosom. Res. 2015, 78, 25–33. [Google Scholar] [CrossRef]
  28. Egede, L.E. Failure to Recognize Depression in Primary Care: Issues and Challenges. J. Gen. Intern. Med. 2007, 22, 701–703. [Google Scholar] [CrossRef]
  29. Fletcher, S.; Chondros, P.; Densley, K.; Murray, E.; Dowrick, C.; Coe, A.; Hegarty, K.; Davidson, S.; Wachtler, C.; Mihalopoulos, C.; et al. Matching Depression Management to Severity Prognosis in Primary Care: Results of the Target-D Randomised Controlled Trial. Br. J. Gen. Pract. 2021, 71, e85–e94. [Google Scholar] [CrossRef]
  30. Fekadu, A.; Demissie, M.; Birhane, R.; Medhin, G.; Bitew, T.; Hailemariam, M.; Minaye, A.; Habtamu, K.; Milkias, B.; Petersen, I.; et al. Under Detection of Depression in Primary Care Settings in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis. Syst. Rev. 2022, 11, 21. [Google Scholar] [CrossRef]
  31. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed.; American Psychiatric Association: Washington, DC, USA, 2013. [Google Scholar]
  32. World Health Organization ICD-11 for Mortality and Morbidity Statistics. Available online: https://icd.who.int/browse/2024-01/mms/en#334423054 (accessed on 29 March 2024).
  33. Simon, G.E.; Moise, N.; Mohr, D.C. Management of Depression in Adults: A Review. JAMA 2024, 332, 141–152. [Google Scholar] [CrossRef]
  34. Riera-Serra, P.; Navarra-Ventura, G.; Castro, A.; Gili, M.; Salazar-Cedillo, A.; Ricci-Cabello, I.; Roldán-Espínola, L.; Coronado-Simsic, V.; García-Toro, M.; Gómez-Juanes, R.; et al. Clinical Predictors of Suicidal Ideation, Suicide Attempts and Suicide Death in Depressive Disorder: A Systematic Review and Meta-Analysis. Eur. Arch. Psychiatry Clin. Neurosci. 2024, 274, 1543–1563. [Google Scholar] [CrossRef]
  35. Arroll, B.; Elley, C.R.; Fishman, T.; Goodyear-Smith, F.A.; Kenealy, T.; Blashki, G.; Kerse, N.; Macgillivray, S. Antidepressants versus Placebo for Depression in Primary Care. Cochrane Database Syst. Rev. 2009, 2009, CD007954. [Google Scholar] [CrossRef] [PubMed]
  36. Cipriani, A.; Furukawa, T.A.; Geddes, J.R.; Malvini, L.; Signoretti, A.; McGuire, H.; Churchill, R.; Nakagawa, A.; Barbui, C.; MANGA Study Group. Does Randomized Evidence Support Sertraline as First-Line Antidepressant for Adults with Acute Major Depression? A Systematic Review and Meta-Analysis. J. Clin. Psychiatry 2008, 69, 1732–1742. [Google Scholar] [CrossRef]
  37. Cuijpers, P.; Sijbrandij, M.; Koole, S.L.; Andersson, G.; Beekman, A.T.; Reynolds, C.F. Adding Psychotherapy to Antidepressant Medication in Depression and Anxiety Disorders: A Meta-Analysis. World Psychiatry Off. J. World Psychiatr. Assoc. WPA 2014, 13, 56–67. [Google Scholar] [CrossRef]
  38. Hasin, D.S.; Sarvet, A.L.; Meyers, J.L.; Saha, T.D.; Ruan, W.J.; Stohl, M.; Grant, B.F. Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers in the United States. JAMA Psychiatry 2018, 75, 336–346. [Google Scholar] [CrossRef]
  39. Saver, B.G.; Van-Nguyen, V.; Keppel, G.; Doescher, M.P. A Qualitative Study of Depression in Primary Care: Missed Opportunities for Diagnosis and Education. J. Am. Board Fam. Med. JABFM 2007, 20, 28–35. [Google Scholar] [CrossRef] [PubMed]
  40. Kato, E.; Borsky, A.E.; Zuvekas, S.H.; Soni, A.; Ngo-Metzger, Q. Missed Opportunities for Depression Screening and Treatment in the United States. J. Am. Board Fam. Med. JABFM 2018, 31, 389–397. [Google Scholar] [CrossRef] [PubMed]
  41. Rhodes, K.V. Mood Disorders in the Emergency Department: The Challenge of Linking Patients to Appropriate Services. Gen. Hosp. Psychiatry 2008, 30, 1–3. [Google Scholar] [CrossRef]
  42. Mekonen, T.; Chan, G.C.K.; Connor, J.P.; Hides, L.; Leung, J. Estimating the Global Treatment Rates for Depression: A Systematic Review and Meta-Analysis. J. Affect. Disord. 2021, 295, 1234–1242. [Google Scholar] [CrossRef]
  43. Evans-Lacko, S.; Aguilar-Gaxiola, S.; Al-Hamzawi, A.; Alonso, J.; Benjet, C.; Bruffaerts, R.; Chiu, W.T.; Florescu, S.; de Girolamo, G.; Gureje, O.; et al. Socio-Economic Variations in the Mental Health Treatment Gap for People with Anxiety, Mood, and Substance Use Disorders: Results from the WHO World Mental Health (WMH) Surveys. Psychol. Med. 2018, 48, 1560–1571. [Google Scholar] [CrossRef]
  44. Yan, G.; Zhang, Y.; Wang, S.; Yan, Y.; Liu, M.; Tian, M.; Tian, W. Global, Regional, and National Temporal Trend in Burden of Major Depressive Disorder from 1990 to 2019: An Analysis of the Global Burden of Disease Study. Psychiatry Res. 2024, 337, 115958. [Google Scholar] [CrossRef]
  45. Harris, M.G.; Kazdin, A.E.; Chiu, W.T.; Sampson, N.A.; Aguilar-Gaxiola, S.; Al-Hamzawi, A.; Alonso, J.; Altwaijri, Y.; Andrade, L.H.; Cardoso, G.; et al. Findings from World Mental Health Surveys of the Perceived Helpfulness of Treatment for Patients with Major Depressive Disorder. JAMA Psychiatry 2020, 77, 830–841. [Google Scholar] [CrossRef] [PubMed]
  46. Chaimowitz, G.A.; Links, P.S.; Padgett, R.W.; Carr, A.C. Treatment-Resistant Depression: A Survey of Practice Habits of Canadian Psychiatrists. Can. J. Psychiatry Rev. Can. Psychiatr. 1991, 36, 353–356. [Google Scholar] [CrossRef] [PubMed]
  47. Branjerdporn, G.; Sarma, S.; McCosker, L.; Dong, V.; Martin, D.; Loo, C. “ECT Should Never Stop”: Exploring the Experiences and Recommendations of ECT Clinical Directors and Anesthetists about ECT during the COVID-19 Pandemic. Front. Psychiatry 2022, 13, 946748. [Google Scholar] [CrossRef] [PubMed]
  48. NICE Depression in Adults: Recognition and Management|Guidance|. Available online: https://www.nice.org.uk/guidance/cg90/chapter/Recommendations#step-1-recognition-assessment-and-initial-management (accessed on 13 December 2020).
  49. NICE Recommendations|Depression in Adults: Treatment and Management|Guidance|NICE. Available online: https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#treatment-for-a-new-episode-of-more-severe-depression (accessed on 22 August 2024).
  50. Kroenke, K.; Spitzer, R.L.; Williams, J.B. The PHQ-9: Validity of a Brief Depression Severity Measure. J. Gen. Intern. Med. 2001, 16, 606–613. [Google Scholar] [CrossRef]
  51. Arroll, B.; Goodyear-Smith, F.; Crengle, S.; Gunn, J.; Kerse, N.; Fishman, T.; Falloon, K.; Hatcher, S. Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in the Primary Care Population. Ann. Fam. Med. 2010, 8, 348. [Google Scholar] [CrossRef]
  52. WHO. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research; World Health Organization: Geneva, Switzerland, 1993. [Google Scholar]
  53. World Health Organization. The ICD-10 Classification of Mental Behavioural Disorders—Clinical Descriptions and Diagnostic Guidelines, 10th ed.; World Health Organization: Geneva, Switzerland, 1992. [Google Scholar]
  54. Beck, A.T.; Ward, C.H.; Mendelson, M.; Mock, J.; Erbaugh, J. An Inventory for Measuring Depression. Arch. Gen. Psychiatry 1961, 4, 561–571. [Google Scholar] [CrossRef]
  55. Zung, W.K. A Self-Rating Depression Scale. Arch. Gen. Psychiatry 1965, 12, 63–70. [Google Scholar] [CrossRef]
  56. Hamilton, M. A Rating Scale for Depression. J. Neurol. Neurosurg. Psychiatry 1960, 23, 56. [Google Scholar] [CrossRef]
  57. Montgomery, S.A.; Asberg, M. A New Depression Scale Designed to Be Sensitive to Change. Br. J. Psychiatry J. Ment. Sci. 1979, 134, 382–389. [Google Scholar] [CrossRef]
  58. NICE (National Institute for Health and Care Excellence). Overview|Depression in Adults with a Chronic Physical Health Problem: Recognition and Management|Guidance|NICE. Available online: https://www.nice.org.uk/guidance/cg91 (accessed on 25 December 2024).
  59. Kruizinga, J.; Liemburg, E.; Burger, H.; Cipriani, A.; Geddes, J.; Robertson, L.; Vogelaar, B.; Nolen, W.A. Pharmacological Treatment for Psychotic Depression. Cochrane Database Syst. Rev. 2021, 12, CD004044. [Google Scholar] [CrossRef]
  60. Lassen, R.H.; Gonçalves, W.; Gherman, B.; Coutinho, E.; Nardi, A.E.; Peres, M.A.; Appolinario, J.C. Medication Non-Adherence in Depression: A Systematic Review and Metanalysis. Trends Psychiatry Psychother. 2024. ahead of print. [Google Scholar] [CrossRef] [PubMed]
  61. Unni, E.J.; Gupta, S.; Sternbach, N. Reasons for Non-Adherence with Antidepressants Using the Medication Adherence Reasons Scale in Five European Countries and United States. J. Affect. Disord. 2024, 344, 446–450. [Google Scholar] [CrossRef] [PubMed]
  62. Taylor, M.J.; Rudkin, L.; Bullemor-Day, P.; Lubin, J.; Chukwujekwu, C.; Hawton, K. Strategies for Managing Sexual Dysfunction Induced by Antidepressant Medication. Cochrane Database Syst. Rev. 2013, 5, CD003382. [Google Scholar] [CrossRef] [PubMed]
  63. Montejo, A.L.; Prieto, N.; de Alarcón, R.; Casado-Espada, N.; de la Iglesia, J.; Montejo, L. Management Strategies for Antidepressant-Related Sexual Dysfunction: A Clinical Approach. J. Clin. Med. 2019, 8, 1640. [Google Scholar] [CrossRef] [PubMed]
  64. McIntyre, R.S.; Alsuwaidan, M.; Baune, B.T.; Berk, M.; Demyttenaere, K.; Goldberg, J.F.; Gorwood, P.; Ho, R.; Kasper, S.; Kennedy, S.H.; et al. Treatment-resistant Depression: Definition, Prevalence, Detection, Management, and Investigational Interventions. World Psychiatry 2023, 22, 394–412. [Google Scholar] [CrossRef]
  65. Rush, A.J.; Trivedi, M.H.; Wisniewski, S.R.; Nierenberg, A.A.; Stewart, J.W.; Warden, D.; Niederehe, G.; Thase, M.E.; Lavori, P.W.; Lebowitz, B.D.; et al. Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report. Am. J. Psychiatry 2006, 163, 1905–1917. [Google Scholar] [CrossRef]
  66. Vida, R.G.; Sághy, E.; Bella, R.; Kovács, S.; Erdősi, D.; Józwiak-Hagymásy, J.; Zemplényi, A.; Tényi, T.; Osváth, P.; Voros, V. Efficacy of Repetitive Transcranial Magnetic Stimulation (rTMS) Adjunctive Therapy for Major Depressive Disorder (MDD) after Two Antidepressant Treatment Failures: Meta-Analysis of Randomized Sham-Controlled Trials. BMC Psychiatry 2023, 23, 545. [Google Scholar] [CrossRef]
  67. Maughan, D.; Molodynski, A. An International Perspective on the Acceptability and Sustainability of Electroconvulsive Therapy. BJPsych Int. 2016, 13, 10–12. [Google Scholar] [CrossRef]
  68. Belay, Y.B.; Engel, L.; Lee, Y.Y.; Le, N.; Mihalopoulos, C. Cost Effectiveness of Pharmacological and Non-Pharmacological Treatments for Depression in Low- and Middle-Income Countries: A Systematic Literature Review. PharmacoEconomics 2023, 41, 651–673. [Google Scholar] [CrossRef]
  69. Rathod, S.; Pinninti, N.; Irfan, M.; Gorczynski, P.; Rathod, P.; Gega, L.; Naeem, F. Mental Health Service Provision in Low- and Middle-Income Countries. Health Serv. Insights 2017, 10, 1178632917694350. [Google Scholar] [CrossRef]
  70. NICE (National Institute for Health and Care Excellence). Recommendations|Bipolar Disorder: Assessment and Management|Guidance|NICE. Available online: https://www.nice.org.uk/guidance/cg185/chapter/Recommendations (accessed on 24 December 2024).
  71. Goes, F.S. Diagnosis and Management of Bipolar Disorders. BMJ 2023, 381, e073591. [Google Scholar] [CrossRef] [PubMed]
  72. Chiang, K.S.; Miklowitz, D.J. Psychotherapy in Bipolar Depression: Effective Yet Underused. Psychiatr. Ann. 2023, 53, 58. [Google Scholar] [CrossRef] [PubMed]
  73. McMahon, K.; Herr, N.R.; Zerubavel, N.; Hoertel, N.; Neacsiu, A.D. Psychotherapeutic Treatment of Bipolar Depression. Psychiatr. Clin. N. Am. 2016, 39, 35–56. [Google Scholar] [CrossRef] [PubMed]
  74. Yilmaz, S.; Huguet, A.; Kisely, S.; Rao, S.; Wang, J.; Baur, K.; Price, M.; O’Mahen, H.; Wright, K. Do Psychological Interventions Reduce Symptoms of Depression for Patients with Bipolar I or II Disorder? A Meta-Analysis. J. Affect. Disord. 2022, 301, 193–204. [Google Scholar] [CrossRef]
  75. Mamukashvili-Delau, M.; Koburger, N.; Dietrich, S.; Rummel-Kluge, C. Long-Term Efficacy of Internet-Based Cognitive Behavioral Therapy Self-Help Programs for Adults with Depression: Systematic Review and Meta-Analysis of Randomized Controlled Trials. JMIR Ment. Health 2023, 10, e46925. [Google Scholar] [CrossRef]
  76. Stuart, R.; Fischer, H.; Leitzke, A.S.; Becker, D.; Saheba, N.; Coleman, K.J. The Effectiveness of Internet-Based Cognitive Behavioral Therapy for the Treatment of Depression in a Large Real-World Primary Care Practice: A Randomized Trial. Perm. J. 2022, 26, 53–60. [Google Scholar] [CrossRef]
  77. Thase, M.E.; Wright, J.H.; Eells, T.D.; Barrett, M.S.; Wisniewski, S.R.; Balasubramani, G.K.; McCrone, P.; Brown, G.K. Improving Efficiency of Psychotherapy for Depression: Computer-Assisted Cognitive-Behavior Therapy Versus Standard Cognitive-Behavior Therapy. Am. J. Psychiatry 2018, 175, 242–250. [Google Scholar] [CrossRef]
  78. Kim, W.; Lim, S.-K.; Chung, E.-J.; Woo, J.-M. The Effect of Cognitive Behavior Therapy-Based Psychotherapy Applied in a Forest Environment on Physiological Changes and Remission of Major Depressive Disorder. Psychiatry Investig. 2009, 6, 245–254. [Google Scholar] [CrossRef]
  79. Lusk, P.; Melnyk, B.M. The Brief Cognitive-Behavioral COPE Intervention for Depressed Adolescents: Outcomes and Feasibility of Delivery in 30-Minute Outpatient Visits. J. Am. Psychiatr. Nurses Assoc. 2011, 17, 226–236. [Google Scholar] [CrossRef]
  80. Tursi, M.F.d.S.; Baes, C.v.W.; Camacho, F.R.d.B.; Tofoli, S.M.d.C.; Juruena, M.F. Effectiveness of Psychoeducation for Depression: A Systematic Review. Aust. N. Z. J. Psychiatry 2013, 47, 1019–1031. [Google Scholar] [CrossRef]
  81. Katsuki, F.; Watanabe, N.; Yamada, A.; Hasegawa, T. Effectiveness of Family Psychoeducation for Major Depressive Disorder: Systematic Review and Meta-Analysis. BJPsych Open 2022, 8, e148. [Google Scholar] [CrossRef] [PubMed]
  82. Conejo-Cerón, S.; Bellón, J.Á.; Motrico, E.; Campos-Paíno, H.; Martín-Gómez, C.; Ebert, D.D.; Buntrock, C.; Gili, M.; Moreno-Peral, P. Moderators of Psychological and Psychoeducational Interventions for the Prevention of Depression: A Systematic Review. Clin. Psychol. Rev. 2020, 79, 101859. [Google Scholar] [CrossRef] [PubMed]
  83. Marx, W.; Manger, S.H.; Blencowe, M.; Murray, G.; Ho, F.Y.-Y.; Lawn, S.; Blumenthal, J.A.; Schuch, F.; Stubbs, B.; Ruusunen, A.; et al. Clinical Guidelines for the Use of Lifestyle-Based Mental Health Care in Major Depressive Disorder: World Federation of Societies for Biological Psychiatry (WFSBP) and Australasian Society of Lifestyle Medicine (ASLM) Taskforce. World J. Biol. Psychiatry Off. J. World Fed. Soc. Biol. Psychiatry 2023, 24, 333–386. [Google Scholar] [CrossRef]
  84. Sarris, J.; O’Neil, A.; Coulson, C.E.; Schweitzer, I.; Berk, M. Lifestyle Medicine for Depression. BMC Psychiatry 2014, 14, 107. [Google Scholar] [CrossRef]
  85. Kvam, S.; Kleppe, C.L.; Nordhus, I.H.; Hovland, A. Exercise as a Treatment for Depression: A Meta-Analysis. J. Affect. Disord. 2016, 202, 67–86. [Google Scholar] [CrossRef]
  86. Greenberg, P.E.; Fournier, A.-A.; Sisitsky, T.; Simes, M.; Berman, R.; Koenigsberg, S.H.; Kessler, R.C. The Economic Burden of Adults with Major Depressive Disorder in the United States (2010 and 2018). PharmacoEconomics 2021, 39, 653–665. [Google Scholar] [CrossRef]
  87. König, H.; König, H.-H.; Konnopka, A. The Excess Costs of Depression: A Systematic Review and Meta-Analysis. Epidemiol. Psychiatr. Sci. 2019, 29, e30. [Google Scholar] [CrossRef]
  88. Barney, L.J.; Griffiths, K.M.; Jorm, A.F.; Christensen, H. Stigma about Depression and Its Impact on Help-Seeking Intentions. Aust. N. Z. J. Psychiatry 2006, 40, 51–54. [Google Scholar] [CrossRef]
Table 1. Themes and subthemes of common challenges of managing depression in clinical practice.
Table 1. Themes and subthemes of common challenges of managing depression in clinical practice.
Themes and Subthemes
  • Managing TRD (persistent partial or non-response to medication, difficulty deciding appropriate person-specific augmentation)
  • Patient adherence to treatment (both for medications and psychotherapy, frustration at the tardy response to treatment, hesitancy for medication, motivation)
  • Managing side effects (sexual, gastrointestinal, agitation, leading to non-adherence)
  • Challenges with psychological services (limited availability, inadequate access especially early in treatment, long waiting, lack of resources)
  • Stigma (associated with psychiatric illnesses and treatment, using medications, being labeled, and perceived social consequences)
  • Medication availability (hospital pharmacies especially in the government sector, guidelines, affordability)
  • Comorbidities (substance use disorders, personality disorders)
  • Psychosocial issues (family attitude, denial, social isolation)
  • Clinical challenges (diagnosis, deciding person-specific treatment strategy, recurrent episodes, managing suicidality)
  • Treatment challenges (inadequate response, resistance to change treatment after non-response, delay in holistic intervention, augmentation strategies, polypharmacy, lack of newer modalities of treatment such as neuromodulation)
  • Continuity of care issues (lack of appropriate follow-up, patient motivation, and engagement)
  • Education and awareness (lack of public awareness, delayed help-seeking, reluctance to use medication, erroneous belief of getting addicted to medications)
Table 2. Common strategies reported for managing TRD.
Table 2. Common strategies reported for managing TRD.
Management Strategies HIC
n (%)		LAMIC
n (%)		Total
n (%)
Antidepressants with second-generation antipsychotics 51 (72.9)54 (80.6)105 (76.6)
Switching antidepressants56 (80.0)47 (70.1)103 (75.2)
Two antidepressants45 (64.3)45 (67.2)90 (65.7)
Antidepressant and lithium39 (55.7)49 (73.1)88 (64.2)
Psychotherapy 46 (65.7)42 (62.7)88 (64.2)
Electroconvulsive therapy 33 (47.1)48 (71.6)81 (59.1)
Increased trial length of antidepressant29 (41.4)25 (37.3)54 (39.4)
Antidepressant and valproate/carbamazepine/lamotrigine27 (38.6)24 (35.8)51 (37.2)
Intravenous ketamine or intranasal esketamine8 (11.4)18 (26.9)26 (19.0)
Antidepressant with thyroid hormone 5 (7.1)21 (31.3)26 (19.0)
Bupropion8 (11.4)17 (25.4)25 (18.2)
Transcranial magnetic stimulation8 (11.4)8 (11.9)16 (11.7)
Table 3. Strategies used for managing bipolar depression.
Table 3. Strategies used for managing bipolar depression.
Strategies HIC
n (%)		LAMIC
n (%)		Total
n (%)
Lithium and antidepressant48 (68.6)45 (67.2)93 (67.9)
Atypical antipsychotic and antidepressant46 (65.7)45 (67.2)91 (66.4)
Lamotrigine and antidepressant33 (47.1)37 (55.2)70 (51.1)
Valproate and antidepressant22 (31.4)31 (46.3)53 (38.7)
Psychotherapy 19 (27.1)21 (31.3)40 (29.2)
Two mood stabilizers10 (14.3)17 (25.4)27 (19.7)
No antidepressant12 (17.1)10 (14.9)22 (16.1)
Others 4 (5.7)11 (16.4)15 (10.9)
Table 4. Side effects posing a challenge to treatment adherence.
Table 4. Side effects posing a challenge to treatment adherence.
Side effectsHIC
n (%)		LAMIC
n (%)		Total
n (%)
Sexual problems 31 (44.4)32 (47.8)63 (46.0)
Weight gain 26 (37.1)23 (34.3)48 (35.0)
Sedation15 (21.4)30 (44.8)43 (31.4)
Gastrointestinal side effects19 (27.1)22 (32.9)41 (29.9)
Agitation 9 (12.8)9 (13.4)17 (12.4)
Insomnia 4 (5.7)6 (9.0)10 (7.3)
Fatigue3 (4.3)2 (3.0)5 (3.6)
Other 14 (20.0)12 (17.9)26 (19.0)
Table 5. Challenges to continuity of care.
Table 5. Challenges to continuity of care.
ChallengesHIC
n (%)		LAMIC
n (%)		Total
n (%)
Non-adherence 54 (77.1)59 (88.1)113 (82.5)
Unresolved psychological stress41 (58.6)50 (74.6)91 (66.4)
Missed appointments42 (60.0)45 (67.2)87 (63.5)
Personality disorders49 (70.0)37 (55.2)86 (62.8)
Substance use47 (67.1)36 (53.7)83 (60.6)
Physical comorbidities40 (57.1)29 (43.3)69 (50.4)
Other psychiatric comorbidities35 (50.0)26 (38.8)61 (44.5)
Other 3 (4.3)4 (6.0)7 (5.1)
Table 6. Themes and subthemes of solutions provided by clinicians to manage the challenges in treating depression in clinical practice.
Table 6. Themes and subthemes of solutions provided by clinicians to manage the challenges in treating depression in clinical practice.
Themes and Subthemes
  • Psychoeducation (public education, schools, workplace, families, family caregivers, patients, regarding illness, treatment, and stigma)
  • Improving access to treatment (ensuring availability of affordable, accessible medications and psychotherapies, reducing waiting time; community-based services, online platform for consultation, prescription, and service delivery)
  • Personalized treatment (provided appropriate medication and psychotherapy based on individual requirements)
  • Training and development of healthcare providers (training for early detection and treatment of depression, supporting healthcare professionals to provide psychological interventions, interdisciplinary collaboration)
  • Managing stigma (prioritizing mental health in public awareness programs, improving cultural perceptions about mental illness and treatment, improving acceptance of mental health care-seeking behavior, multiagency work involving government and media de-stigmatizing depression)
  • Improving continuity of care (enhanced communication between professionals, primary, and secondary care, rapid access to comprehensive holistic care for depression including both medications and psychological intervention, supporting regular follow-up and monitoring progress)
  • Government and policy support (funding for medications and other treatment modalities, increased insurance cover, policy-making depression treatment more accessible and affordable)
  • Research and innovation (research on new treatment modalities, biomarkers for treatment response, management for comorbidities, long-term effects of current treatments)
  • Social support (peer-led support groups for emotional support, community outreach, social networks for support, encouraging family involvement in the treatment process)
  • Medication management (optimize medication to avoid polypharmacy, reduce side effects, regular reviews to check response, effectiveness, and adjustment, ensure availability of a range of antidepressants for improved flexibility in treatment, explore non-medicinal interventions e.g., neuromodulation)
  • Sustaining long-term recovery (ongoing support following improvement, long-term lifestyle changes, addressing relapses early, proactive follow-ups)
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Kar, N. Challenges in Managing Depression in Clinical Practice: Result of a Global Survey. Pharmacoepidemiology 2025, 4, 5. https://doi.org/10.3390/pharma4010005

AMA Style

Kar N. Challenges in Managing Depression in Clinical Practice: Result of a Global Survey. Pharmacoepidemiology. 2025; 4(1):5. https://doi.org/10.3390/pharma4010005

Chicago/Turabian Style

Kar, Nilamadhab. 2025. "Challenges in Managing Depression in Clinical Practice: Result of a Global Survey" Pharmacoepidemiology 4, no. 1: 5. https://doi.org/10.3390/pharma4010005

APA Style

Kar, N. (2025). Challenges in Managing Depression in Clinical Practice: Result of a Global Survey. Pharmacoepidemiology, 4(1), 5. https://doi.org/10.3390/pharma4010005

Article Metrics

Back to TopTop