Insights for the treatment of depression in the Brazilian Public Health System

Dear Editor,

A recent article by Cleare et al.¹ provides valuable insights into the pharmacological management of treatment-resistant depression (TRD), particularly regarding the use of adjunctive agents. Over a 52-week follow-up period, the study found that participants treated with adjunctive quetiapine exhibited significantly lower depressive symptom severity, reduced healthcare costs, greater gains in Quality-Adjusted Life Years (QALYs), and no differences in discontinuation rates compared to those receiving lithium. These findings raise important considerations for the treatment of depressive episodes within the Brazilian Public Health System (Sistema Único de Saúde, SUS), especially in cases of TRD.

Taking the state of São Paulo as an example, which is the most populous in Brazil, with over 44 million inhabitants, representing approximately 20% of the country’s population, the estimated prevalence of depression in primary care is around 25%.² Most of these patients receive treatment through the public health system, where certain medications are provided free of charge with a medical prescription. Available treatments for depressive episodes include selective serotonin reuptake inhibitors (fluoxetine and sertraline), tricyclic antidepressants (clomipramine, amitriptyline, nortriptyline, and imipramine), and, in some regions, the serotonin and norepinephrine reuptake inhibitor venlafaxine.

Regarding evidence-based adjunctive strategies,³ only lithium, risperidone, and immediate-release methylphenidate are currently available. Quetiapine, along with other atypical antipsychotics, is included in the formulary solely for patients diagnosed with bipolar disorder or schizophrenia, consequently making its use in major depressive disorder inaccessible through the public system. Furthermore, given Brazil’s socioeconomic landscape, many patients cannot afford the monthly cost of private prescriptions. This is particularly relevant considering that among primary care users, psychiatric diagnoses are more prevalent in individuals with lower income, unemployment, and limited access to education.²

In Latin America, Brazil has the highest prevalence of TRD, ultimately affecting nearly 40% of patients with depression, with higher rates observed in public healthcare settings compared to private services.⁴ In addition, compared to non-resistant depressive episodes, TRD in Brazil imposes significantly greater costs on the public health system, thus requiring increased resource allocation, including higher hospitalization rates and multiple pharmacological trials, with pharmaceutical expenditures representing the largest proportion of total costs.⁵

Given this scenario and considering that quetiapine is among the most effective adjunctive treatments for TRD,⁶ for mental health professionals, particularly those working in the public sector, to advocate for expanding treatment options is crucial. Doing so could improve response and remission rates, enhance patient quality of life, and potentially reduce the long-term financial burden on the healthcare system.

REFERENCES

• ^1. 1. Cleare AJ, Kerr-Gaffney J, Goldsmith K, et al.; LQD Study Group. Clinical and cost-effectiveness of lithium versus quetiapine augmentation for treatment-resistant depression: a pragmatic, open-label, parallel-group, randomised controlled superiority trial in the UK. Lancet Psychiatry. 2025;12(4):276–88. https://doi.org/10.1016/S2215-0366(25)00028-8. Erratum in: Lancet Psychiatry. 2025;12(6):e9. PMID: 40113355; https://doi.org/10.1016/S2215-0366(25)00133-6.
  » https://doi.org/10.1016/S2215-0366(25)00028-8
• ^2. Gonçalves DA, Mari JJ, Bower P, et al. Brazilian multicentre study of common mental disorders in primary care: rates and related social and demographic factors. Cad Saude Publica. 2014;30(3):623–32. PMID: 24714951; https://doi.org/10.1590/0102-311x00158412.
  » https://doi.org/10.1590/0102-311x00158412
• ^3. Lam RW, Kennedy SH, Adams C, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 update on clinical guidelines for management of major depressive disorder in adults: Réseau canadien pour les traitements de l’humeur et de l’anxiété (CANMAT) 2023: mise à jour des lignes directrices cliniques pour la prise en charge du trouble dépressif majeur chez les adultes. Can J Psychiatry. 2024;69(9):641–87. https://doi.org/10.1177/07067437241245384. Erratum in: Can J Psychiatry. 2025;70(8):652. PMID: 38711351; https://doi.org/10.1177/07067437251349087.
  » https://doi.org/10.1177/07067437241245384
• ^4. Soares B, Kanevsky G, Teng CT, et al. Prevalence and impact of treatment-resistant depression in Latin America: a prospective, observational study. Psychiatr Q. 2021;92(4):1797–815. PMID: 34463905; https://doi.org/10.1007/s11126-021-09930-x.
  » https://doi.org/10.1007/s11126-021-09930-x
• ^5. Lepine BA, Moreno RA, Campos RN, Couttolenc BF. Treatment-resistant depression increases health costs and resource utilization. Braz J Psychiatry. 2012;34(4):379–88. PMID: 23429808; https://doi.org/10.1016/j.rbp.2012.05.009.
  » https://doi.org/10.1016/j.rbp.2012.05.009
• ^6. Zhou X, Ravindran AV, Qin B, et al. Comparative efficacy, acceptability, and tolerability of augmentation agents in treatment-resistant depression: systematic review and network meta-analysis. J Clin Psychiatry. 2015;76(4):e487–e498. PMID: 25919841; https://doi.org/10.4088/JCP.14r09204.
  » https://doi.org/10.4088/JCP.14r09204

• Sources of funding:
  This study was partially supported by the Coordenação para Aperfeiçoamento de Pessoa de Nível Superior (CAPES, code 001).

Acknowledgments:

We extend our gratitude to all patients who volunteered to participate in this research and formed the study sample.

Edited by

• Editor responsible for the evaluation process:
  Paulo Manuel Pêgo-Fernandes, MD, PhD

Publication Dates

• Publication in this collection
  27 Oct 2025
• Date of issue
  2025

History

• Received
  08 Apr 2025
• Accepted
  14 May 2025