Current treatment for depression in primary care and other out-patient settings demonstrates a pattern that is incongruous with the magnitude of the burden of depression suggested by its associated disability.

To review important considerations in current depression treatment with a focus on antidepressant use.

Factors influencing the under treatment of depression in real-world settings are examined.

Patient and clinician behaviour as well as the incentives created by the health care system affect the likelihood of realising effective antidepressant therapy in practice.

Given the complexities of clinical practice, selection criteria for an antidepressant should include safety, efficacy and tolerability, as well as the ability of the antidepressant to deliver real-world efficacy while balancing health care costs in the long term.

There is inconsistent evidence regarding the influence of general cognitive abilities on the long-term course of depression.

To investigate the association between general childhood cognitive abilities and adult depression outcomes.

We conducted a cohort study using data from 633 participants in the New England Family Study with lifetime depression. Cognitive abilities at age 7 were measured using the Wechsler Intelligence Scale for Children. Depression outcomes were assessed using structured diagnostic interviews administered up to four times in adulthood between ages 17 and 49.

In analyses adjusting for demographic factors and parental psychiatric illness, low general cognitive ability (i.e. IQ<85 v. IQ>115) was associated with recurrent depressive episodes (odds ratio (OR) = 2.19, 95% CI 1.20–4.00), longer episode duration (rate ratio 4.21, 95% CI 2.24–7.94), admission to hospital for depression (OR = 3.65, 95% CI 1.34–9.93) and suicide ideation (OR = 3.79, 95% CI 1.79–8.02) and attempt (OR = 4.94, 95% CI 1.67–14.55).

Variation in cognitive abilities, predominantly within the normal range and established early in childhood, may confer long-term vulnerability for prolonged and severe depression. The mechanisms underlying this vulnerability need to be established to improve the prognosis of depression among individuals with lower cognitive abilities.

Imaging studies in depression of the elderly are often small and highly selective.

To investigate a large group of elderly depressed patients in order to assess changes in clinical, imaging and neuropsychological variables at follow-up.

Patients (n=175, age range 65–91 years) with clinical depression were identified from consecutive local referrals. Clinical interviews, neuropsychological tests and SPECT scans were carried out at referral and at two-year follow-up.

Of 84 re-examined patients, 46.5% were well, 9.5% were ill, 33% partially recovered and 11% had developed dementia. Duration of illness before index assessment was the only factor to predict outcome. Thirty-nine patients could be scanned and followed up. There were no differences between patients with good or poor depressive outcome on SPECT. Ten clinically improved patients could be re-examined with SPECT. There were relative increases in right cingulate gyrus and right cerebellum at follow-up.

The patient group was comparable with other studies showing high levels of residual depressive symptoms. Activity changes in limbic cortex are implicated in depression of old age.

Examination of the brain regions that show aberrant activations and/or deactivations during semantic word generation could pave the way for a better understanding of the neurobiology of cognitive dysfunction in schizophrenia.

To examine the pattern of functional magnetic resonance imaging blood oxygen level dependent activations and deactivations during semantic word generation in schizophrenia.

Functional magnetic resonance imaging was performed on 24 participants with schizophrenia and 24 matched healthy controls during an overt, paced, ‘semantic category word generation’ condition and a baseline ‘word repetition’ condition that modelled all the lead-in/associated processes involved in the performance of the generation task.

The brain regions activated during word generation in healthy individuals were replicated with minimal redundancies in participants with schizophrenia. The individuals with schizophrenia showed additional activations of temporo-parieto-occipital cortical regions as well as subcortical regions, despite significantly poorer behavioural performance than the healthy participants. Importantly, the extensive deactivations in other brain regions during word generation in healthy individuals could not be replicated in those with schizophrenia.

More widespread activations and deficient deactivations in the poorly performing participants with schizophrenia may reflect an inability to inhibit competing cognitive processes, which in turn could constitute the core information-processing deficit underlying impaired word generation in schizophrenia.

Late-life depression (LLD) is a disabling disorder and antidepressants are ineffective in as many as 60% of cases. Converging evidence shows a strong correlation between LLD and subsequent risk of cardiovascular disease. There is a need for new, well-tolerated, non-pharmacological augmentation interventions that can treat depressive symptoms as well as improve heart rate variability (HRV), an important prognostic marker for development of subsequent cardiovascular disease. Meditation-based techniques are of interest based on positive findings in other samples.

We aimed to assess the efficacy of Sahaj Samadhi meditation (SSM), an underevaluated, standardised and manualised meditation intervention, on HRV and depressive symptoms.

Eighty-three men and women aged 60–85 years, with mild to moderate depression and receiving treatment as usual (TAU) were randomised to either the SSM or TAU arm. Those allocated to SSM attended 4 consecutive days of group meditation training, using personalised mantras followed by 11 weekly reinforcement sessions. HRV and Hamilton Rating Scale for Depression (HRSD; 17-item) score were measured at baseline and 12 weeks.

All time and frequency domain measures of HRV did not significantly change in either arm. However, there was significant improvement in the SSM arm, compared with TAU, on the HRSD (difference in mean, 2.66; 95% CI 0.26–5.05; P = 0.03).

Compared with TAU, SSM is associated with improvements in depressive symptoms but does not significantly improve HRV in patients with LLD. These results need to be replicated in subsequent studies incorporating a group-based, active control arm.

R.I.N. is the Director of Research and Health Promotion for the Art of Living Foundation, Canada and supervised the staff providing Sahaj Samadhi meditation. S.R. has received research funding from Satellite Healthcare for a mindfulness meditation trial in patients on haemodialysis. The remaining authors report no financial or other relationship relevant to the subject of this article.