Why antidepressants are not antidepressants: STEP‐BD, STAR*D, and the return of neurotic depression

The widely held clinical view of ‘antidepressants’ as highly effective and specific for the treatment of all types of depressive disorders is exaggerated. This sobering conclusion is supported by recent findings from the NIMH‐sponsored STEP‐BD and STAR*D projects. Antidepressants have limited short‐term efficacy in unipolar depressive disorders and less in acute bipolar depression; their long‐term prophylactic effectiveness in recurrent unipolar major depression remains uncertain, and is doubtful in recurrent bipolar depression. These limitations may, in part, reflect the excessively broad concept of major depression as well as unrealistic expectations of universal efficacy of drugs considered ‘antidepressants.’ Treatment‐refractory depression may reflect failure to distinguish depressive conditions, particularly bipolar disorder, that are inherently less responsive to antidepressants. Antidepressants probably should be avoided in bipolar depression, mixed manic‐depressive states, and in neurotic depression. Expectations of antidepressants for specific types of patients with symptoms of depression or anxiety require critical re‐evaluation. A revival of the concept of neurotic depression would make it possible to identify patients with mild‐to‐moderate, chronic or episodic dysthymia and anxiety who are unlikely to benefit greatly from antidepressants. Diagnostic criteria for a revival of the concept of neurotic depression are proposed.