One‐quarter of patients with depression may go on to develop chronic depression( Boschloo 2014). This rate of remission, however, likely overestimates the benefit because, using these common criteria, as many as half of the patients classified as being in remission do not consider themselves to be in remission ( Zimmerman 2006) other factors such as spontaneous improvement and placebo effects may partially or fully explain the observed improvement in individual patients. The largest trial to investigate the effectiveness of antidepressant treatment for depression, designed to mimic clinical practice, found that approximately one‐quarter of the participants achieved remission after initial treatment with a selective serotonin reuptake inhibitor (SSRI) ( Kirsch 2018) remission was defined in the trial as a total score on the Hamilton Depression Rating Scale ( Hamilton 1967) of 7 or lower ( Kirsch 2018). Most people with moderate to severe depression do not achieve remission following initial treatment with antidepressants, which is the usual recommended first‐line treatment, ideally in combination with psychotherapy ( RANZCP 2018 WFSBP 2017). The World Health Organization (WHO) estimates that more than 264 million people suffer from depression worldwide ( WHO 2019) such estimates should be interpreted with caution, however, as they are based on diagnostic categories thatlikely have low validity in many parts of the world ( Summerfield 2008). Among eight low‐ to middle‐income countries, which included Colombia, Mexico and Ukraine, it was estimated at a mean of 11.1% ( Bromet 2011). Among 10 high‐income countries, which included Germany, Japan, and the US, lifetime prevalence was estimated at a mean of 14.6% ( Bromet 2011). The lifetime prevalence of depression varies geographically. Depending on the diagnostic system, a depressive episode is characterised by a period of almost daily depressed mood, reduced energy or fatigue, or loss of interest or pleasure in activities, accompanied by other symptoms such as difficulty concentrating, feelings of worthlessness, excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, and psychomotor agitation or retardation ( APA 20). The clinical diagnosis of depression is defined in the main classificatory diagnostic systems, the International Classification of Diseases (ICD) ( WHO 1992) and Diagnostic and Statistical Manual of Mental Disorders (DSM) ( APA 2013)), by symptoms forming a syndrome and causing impairment ( Malhi 2018).
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