Links To And Excerpts From Clinical Practice Guidelines for the management of Depression

Here is a list of Depression Assessment Instruments from the APA.

These instruments are relevant to the treatment of depression.

In this post I link to and excerpt from Clinical Practice Guidelines for the management of Depression [PubMed Abstract] [Full-Text HTML] [Full-Text PDF].

All that follows is from the above guideline.

ASSESSMENT AND EVALUATION

FORMULATING A TREATMENT PLAN

EVALUATE THE SAFETY OF PATIENT AND OTHERS

Place some mental health instruments for these factors.

CHOICE OF TREATMENT SETTINGS

THERAPEUTIC ALLIANCE

ENHANCED TREATMENT COMPLIANCE

ADDRESS EARLY SIGNS OF RELAPSE

TREATMENT OPTIONS FOR MANAGEMENT FOR DEPRESSION

Antidepressants

Dose and duration of antidepressants

Patients who have started taking an antidepressant medication should be carefully monitored to assess the response to pharmacotherapy as well as the emergence of side effects and safety. Factors to consider when determining the frequency of monitoring include severity of illness, patient’s co-operation with treatment, the availability of social support and the presence of comorbid general medical problems. Visits may be kept frequent enough to monitor and address suicidality and to promote treatment adherence. Improvement with pharmacotherapy can be observed after 4-6 weeks of treatment. If at least a moderate improvement is not observed in this time period, reappraisal and adjustment of the pharmacotherapy should be considered.

Put in mental health monitoring form.

Psychotherapeutic interventions

Cognitive behavioral therapy (CBT) and interpersonal therapy are the psychotherapeutic approaches that have the best documented efficacy in the literature for management of depression. When psychodynamic psychotherapy is used as specific treatment, in addition to symptom relief it is frequently with broader long term goals.

Psychoeducation to the patient and, when appropriate, to the family

Education concerning depression and its treatments can be provided to all patients. When appropriate, education can also be provided to involved family members.

Combination of pharmacotherapy and Psychotherapy

There is class of patients who may require the combination of pharmacotherapy and psychotherapy. In general, the same issues that influence the choice of medication or psychotherapy when used alone should be considered when choosing tre

PHASES OF ILLNESS/TREATMENT

Management of depression can be broadly divided into three phases, i.e., acute phase, continuation phase and maintenance phase. Maintenance phase of treatment is usually considered when patient has recurrent depressive disorder.

ACUTE PHASE TREATMENT

The goal of acute phase treatment is to achieve remission, as presence of residual symptoms increase the risk of chronic depression, poor quality of life and also impairs recovery from physical illness. Treatment generally results in improvement in quality of life and better functional capacity. The various components of acute phase treatment are shown in Table-10 and the treatment algorithm is shown in figure-figure-22 and and33.

Antidepressant medication may be used as initial treatment modality for patients with mild, moderate, or severe major depressive disorder. Clinical features that may suggest that medication are the preferred treatment modality includes history of prior positive response to antidepressant medication, severity of symptoms, significant sleep and appetite disturbance, agitation, or anticipation of the need for maintenance therapy. Patients with severe depression with psychotic features will require use of combination of antidepressant and antipsychotic medication and/or ECT.

The initial selection of an antidepressant medication is largely be based on the anticipated side effects, the safety or tolerability of these side effects for individual patients, patient preference and comorbid physical illnesses.

Improvement with pharmacotherapy can be observed after 4-6 weeks of treatment. If at least a moderate improvement is not observed in this time period, reappraisal and adjustment of the pharmacotherapy maybe considered.

If at least some improvement (>25%) is not observed following 4 week of pharmacotherapy, a reappraisal of the treatment regimen be conducted and a change in antidepressant may be considered. When patient shows 25-50% improvement during the initial 4 weeks of antidepressant trial, the dose must be optimized to the maximum tolerable dose. If there is less than 50% improvement with 6-8 weeks of maximum tolerable dose and the medication compliance is good, a change in antidepressant may be considered.

If after 4-8 weeks of treatment, if a moderate improvement is not observed, then a thorough review and reappraisal of the diagnosis, complicating conditions and issues, and treatment plan may be conducted. Reappraisal of the treatment regimen may also include evaluation of patient adherence and pharmacokinetic/pharmacodynamic factors. Following this review, the treatment plan can be revised by implementing one of several therapeutic options, including maximizing the initial medication treatment, switching to another antidepressant medication, augmenting antidepressant medications with other agents/psychotherapy/ECT. Maximizing the initial treatment regimen is perhaps the most conservative strategy. While using the higher therapeutic doses, patients are to be closely monitored for an increase in the severity of side effects or emergence of newer side effects.

Switching to a different antidepressant medication is a common strategy for treatment-refractory patients, especially those who have not shown at least partial response to the initial medication regimen. There is no consensus about switching and patients can be switched to an antidepressant medication from the same pharmacologic class (e.g., from an SSRI to another SSRI) or to one from a different pharmacologic class (e.g., from an SSRI to a tricyclic antidepressant). Some expert suggests that while switching, a drug with a different or broader mechanism of action may be chosen.

Augmentation of antidepressant medications may be helpful, particularly for patients who have had a partial response to initial antidepressant monotherapy. Options include adding a second antidepressant medication from a different pharmacologic class, or adding another adjunctive medication such as lithium, psychostimulants, modafinil, thyroid hormone, an anticonvulsant etc. Adding, changing, or increasing the intensity of psychotherapy may be considered for patients who do not respond to medication treatment. Following any change in treatment, close monitoring need to be done. If at least a moderate level of improvement in depressive symptoms is not seen after an additional 4–8 weeks of treatment, another thorough review need to be done. This reappraisal may include verifying the patient’s diagnosis and adherence; identifying and addressing clinical factors that may be preventing improvement, such as the presence of comorbid general medical conditions or psychiatric conditions (e.g., alcohol or substance abuse); and identifying and addressing psychosocial issues that may be impeding recovery. If no new information is uncovered to explain the patient’s lack of adequate response, depending on the severity of depression, ECT maybe considered.

Choice of a specific psychotherapy:

Out of the various psychotherapeutic interventions used for management of depression, there is robust level of evidence for use of CBT.

Psychotherapy is usually recommended for patients with depression who are experiencing stressful life events, interpersonal conflicts, family conflicts, poor social support and comorbid personality issues.

Besides the use of specific psychotherapy, all patients and their caregivers may receive psychoeducation about the illness.

TREATMENT IN CONTINUATION PHASE

start here

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