For many years we have wanted to have treatments for depression with a genuinely fast onset of effect. Quetiapine, recently licensed for the acute for the acute treatment of bipolar depression has shown a rapid separation from placebo at one week in all five pivotal placebo-controlled studies. This study programme has also shown that the comparator treatments, lithium and paroxetine, are not effective in bipolar depression where quetiapine is effective. The finding underlines increasing concerns about the role of lithium in bipolar depression and indicates that in addition to concerns about rates of switches to mania are issues concerning lack of efficacy with antidepressants. Recent results in monotherapy in MDD and GAD at low doses of 150mg also show an early and good response at a clinically relevant level.

The license of agomelatine for MDD in the EU brings a new approach to treatment with good tolerability and a fast effects on the core symptom of sleep disturbance followed by the other symptoms of depression. Sleep disturbance has been neglected as an important presenting symptoms of MDD and the commonest residual symptoms with SSRI, DVS the metabolite of venlafaxine is seen to deliver comparable efficacy to venlafaxine at a lower than expected dose. At 50mg to 100mg it has adverse events close to placebo. This raises questions as to whether the whole development programme for SNRIs has been pitched for too high a dose on the misapprehension of superior efficacy. The focus is now better tolerability and therefore better compliance.