What are the stepwise management guidelines for depression and anxiety according to Australian (AUST) guidelines?

From the Guidelines

Australian guidelines for depression and anxiety recommend a stepped care approach, prioritizing treatment of depressive symptoms when both conditions are present, as suggested by the most recent evidence 1.

Stepwise Management Guidelines

The management of depression and anxiety involves a stepped care approach, matching treatment intensity to illness severity.

• For mild depression and anxiety, the first step involves:
  • Lifestyle modifications (regular exercise, adequate sleep, stress reduction)
  • Psychoeducation
  • Self-help resources
• If symptoms persist or are moderate, psychological therapies are recommended, particularly cognitive behavioral therapy (CBT), which can be delivered face-to-face, online, or via telehealth.

Medication Introduction

For moderate to severe depression, medication is typically introduced, with SSRIs (such as sertraline 50-200mg daily, escitalopram 10-20mg daily) as first-line options due to their favorable side effect profile and efficacy, as supported by previous guidelines 1.

• SNRIs (venlafaxine 75-225mg daily, duloxetine 30-120mg daily) are often second-line choices.

Treatment Duration and Monitoring

Medication should be continued for at least 6-12 months after symptom resolution to prevent relapse.

• Regular monitoring is essential throughout treatment, with assessments every 1-2 weeks initially, then monthly once stable.

Severe or Treatment-Resistant Cases

For severe or treatment-resistant cases, combination therapy (medication plus psychological treatment), switching medications, augmentation strategies (adding mirtazapine, quetiapine, or lithium), or referral for specialized treatments like electroconvulsive therapy may be necessary.

Key Considerations

The choice of an anxiolytic should be informed by the adverse effect profiles of the medications; tolerability of treatment, including the potential for interaction with other current medications; response to prior treatment; and patient preference, as outlined in previous guidelines 1.

• Patients should be warned of any potential harm or adverse effects, and caution is warranted with respect to the use of benzodiazepines in the treatment of anxiety, specifically over the longer term.

From the Research

Stepwise Management of Depression and Anxiety

According to the Australian guidelines, the stepwise management of depression and anxiety involves the following steps:

• Assessment: Excluding a medical cause, identifying features of specific anxiety disorders, and assessing the degree of distress 2
• Psychoeducation: Educating patients about their condition and treatment options
• Psychological treatments: Cognitive behavioral therapy (CBT) is a recommended first-line treatment for anxiety disorders 2, 3
• Pharmacological treatments: Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are recommended first-line pharmacological agents for treating anxiety disorders 2, 3

Treatment Options for Depression

For depression, the treatment options include:

• Psychotherapy: Specific forms of psychotherapy, such as cognitive therapy, behavioral activation, problem-solving therapy, interpersonal therapy, brief psychodynamic therapy, and mindfulness-based psychotherapy, have been shown to be effective in improving symptoms 4
• Antidepressant medications: More than 20 antidepressant medications have been shown to be effective in improving symptoms, with SSRIs being a commonly recommended first-line treatment 4, 5
• Combined treatment: Combining psychotherapy with antidepressant medication may be preferred, especially for more severe or chronic depression 4

Treatment Options for Anxiety

For anxiety, the treatment options include:

• CBT: CBT is a recommended first-line treatment for anxiety disorders 2, 3
• Pharmacotherapy: SSRIs and SNRIs are recommended first-line pharmacological agents for treating anxiety disorders 2, 3
• Combination of CBT and pharmacotherapy: The combination of CBT and pharmacotherapy may be considered for treating anxiety disorders, especially for more severe cases 3

Routine Screening and Management

Routine screening for depression and anxiety in primary care is recommended, using validated screening tools 6 An algorithm can be developed to guide healthcare providers in assessing and managing anxiety and depression, including education, counseling referrals, and medication therapy if warranted 6