A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.

The results lend support to the emerging evidence that resistance to treatment in late-onset depression may be associated with impaired executive function. Subtle cerebrovascular mechanisms may be involved.

Leukoaraiosis (LA) has been associated with abnormalities of both large and small blood vessels. This study attempts to clarify the pathogenesis of LA by testing the hypothesis that increased frequency of LA with occlusive extra-cranial arterial disease results directly from global reduction in cerebral blood flow (CBF). Thirty-five normal subjects and 55 patients with carotid stenosis (>70%) were studied using MR. CBF was measured using phase contrast MR angiography and LA was scored using previously validated scoring system. Patients were divided into those with evidence of previous infarction on MRI and those without. LA was more severe in patients than in normal subjects (P<0.01) and correlated with age in normal subjects but not in patients. CBF in patients with (809+/-214 ml/min) and without infarction (mean 792+/-181 ml/min) was significantly lower than in normal subjects (mean 1073+/-194 ml/min). There was no correlation between the severity of LA and measured CBF in any group. The severity of LA is greater in patients with severe carotid stenosis but is not correlated to reductions in CBF. This suggests that microvascular abnormality is the dominant pathogenetic factor in LA even in the presence of severe stenotic/occlusive large vessel disease.

There seems reasonable, if depressing, agreement from studies of mixed aged subjects and elderly subjects in psychiatric settings that nonresponse or poor response to a course of an antidepressant occurs in at least one-third of depressed patients. The figure may be higher in elderly patients in general and those with poor physical health. The human cost of chronic depression is highlighted in the Medical Outcomes Study. The level of functional impairment and intereference with quality of life associated with depression was comparable with or worse than that of eight major chronic medical conditions, including diabetes, arthritis and severe coronary artery disease. The final tragedy for unremitting depression may of course be suicide.

Editor-It should be difficult for any doctor to ignore Abbasi's recent article on "third world" debt. 1 The state of health care available to families in between half and two thirds of the world is unacceptable, and the great differences in quality of health care between rich and poor countries are unethical. 2 However, the experiences of our aid agency in trying to develop hospital care for children in disadvantaged countries leads us to be cautious about advocating simply a cancellation of debts. We have witnessed that an input of money alone to countries which are poorly governed, and where corruption is a way of life, may fail to reach the most vulnerable and needy within the community.Our agency's view is that all debt to poor and disadvantaged countries should be cancelled but in a more sustainable way than by releasing states from their repayments. Money earmarked for debt repayment should be retrieved but ploughed back fully and immediately into the country's healthcare and education systems. We suggest that this is implemented through the appointment in each repaying country of carefully chosen advocates for women and children. Ideally, partners appointed from within the United Nations should support these local delegates. A committee formed between the UN partners and delegates from the country repaying the debt should thereby ensure that all the money that has been repaid to rich countries is used for health care and education.Such a system would be more difficult to organise than simple cancellation of debt. Care would have to be taken to ensure that existing levels of finance for health care and education are maintained in addition to money resulting from debt repayment. The repayment of debts by the "third world" to rich countries who have prospered from earlier exploitation clearly represents an evil. However, our response to this should be "street wise" and should ensure that the abolition of debt results in maximum benefit to the most vulnerable members of disadvantaged countries.