Treatment selection in depression: the role of clinical judgment.

The selection of treatment in depression should be filtered by clinical judgment, taking into consideration a number of clinical variables, such as characteristics and severity of depressive episode, co-occurring symptomatology and problems (not necessarily syndromes), medical comorbidities, and patient’s history with particular reference to treatment of previous episodes, if they occurred. Such information should be placed within what is actually available in the specific treatment setting and should be integrated with the patient’s preferences. In clinical practice, on the one end, clinical decisions may be affected by irrational factors (eg, exposure to massive doses of pharmaceutical propaganda or familiarity with a specific psychotherapy or medication). On the other end, psychiatrists often use sophisticated forms of clinical judgment that are suitable for clinical challenges but are not addressed by current research strategies. There is increasing awareness of the need of differentiating depression according to specific subtypes, yet clear-cut indications for these subdivisions are still missing. The role of biomarkers, despite many promising research strategies, is still far from offering reliable clinical guidance. In the meanwhile, there are important indications that come from clinical research. Treatment of depression may be conceptualized as integrated treatment of the various components of symptomatology, lifestyle, and social adjustment. An integrated treatment model, discussed in detail elsewhere, is realistic and practical, and not just idealistic. It may be frustrating to those who like oversimplified biological models; however, approaches that integrate clinimetrics, patient priorities, lifestyle issues, and clinical judgment are more in keeping with the complexity of clinical situations and the challenge of depression treatment.