What are the guidelines for managing depression?

Guidelines for Managing Depression

The management of depression should include both psychotherapy (such as CBT or IPT-A) and/or antidepressant treatment (such as SSRIs) as first-line treatments, with the treatment plan customized according to depression severity, suicide risk, and comorbid conditions. 1

Assessment and Diagnosis

• Depression is a serious psychiatric illness with extensive acute and chronic morbidity and mortality, with only 50% of adolescents diagnosed before reaching adulthood 1
• Major depressive disorder (MDD) is characterized by discrete episodes of at least 2 weeks' duration involving changes in affect, cognition, and neurovegetative functions 1
• Depression severity can be classified as:
  • Mild: 5-6 symptoms that are mild in severity with minimal functional impairment
  • Moderate: Between mild and severe
  • Severe: All depressive symptoms or severe functional impairment 1
• Approximately 9% of US adults experience major depression each year, with a lifetime prevalence of approximately 17% for men and 30% for women 2

First-Line Treatment Recommendations

Psychotherapy Options

• Recommended evidence-based psychotherapies include:
  • Cognitive Behavioral Therapy (CBT): Targets patient's thoughts and behaviors to improve mood
  • Interpersonal Psychotherapy (IPT-A): Focuses on interpersonal problems that may cause or exacerbate depression
  • Problem-solving therapy, behavioral activation, brief psychodynamic therapy, and mindfulness-based psychotherapy 1, 2
• Psychotherapy is recommended as first-line treatment, with evidence showing medium-sized effects in symptom improvement over usual care (standardized mean difference ranging from 0.50 to 0.73) 2

Pharmacotherapy Options

• Selective Serotonin Reuptake Inhibitors (SSRIs) are first-line pharmacological treatment 3
• Fluoxetine is the only FDA-approved antidepressant for children and adolescents with depression, while escitalopram is approved for adolescents aged 12 years and older 1
• For adults, 21 antidepressant medications have shown small to medium-sized effects in symptom improvement over placebo (standardized mean difference ranging from 0.23 for fluoxetine to 0.48 for amitriptyline) 2
• Maintenance treatment with antidepressants should continue for 6-12 months after full resolution of symptoms to prevent relapse 1
• For recurrent depression, monitoring for up to 2 years is recommended due to high recurrence rates 1

Combined Treatment Approach

• Psychotherapy combined with antidepressant medication may be preferred, especially for more severe or chronic depression 2
• A network meta-analysis showed greater symptom improvement with combined treatment than with psychotherapy alone (SMD, 0.30) or medication alone (SMD, 0.33) 2
• For patients showing partial response to SSRI treatment at maximum tolerated dosage, the addition of evidence-based psychotherapy should be considered 1

Management of Treatment-Resistant Depression

• If improvement is not seen within 6-8 weeks of treatment, mental health consultation should be considered 1
• Causes of partial response should be explored, including:
  • Poor adherence to treatment
  • Comorbid disorders
  • Ongoing conflicts or abuse 1
• Second-line medication options when initial antidepressant is ineffective include:
  • Changing antidepressant medication
  • Adding a second antidepressant
  • Augmenting with a non-antidepressant medication 2
• For patients with MDD who have shown partial or no response to two or more adequate pharmacologic treatment trials, repetitive transcranial magnetic stimulation (rTMS) may be considered 1

Collaborative Care Models

• Primary care clinicians should actively support depressed patients referred to mental health services to ensure adequate management 1
• Collaborative care programs, including systematic follow-up and outcome assessment, improve treatment effectiveness (SMD, 0.42 compared to usual care) 2
• Roles and responsibilities should be clearly communicated and agreed upon between primary care clinicians and mental health providers 1

Special Considerations

• Bright light therapy is recommended for persons with mild to moderate MDD, regardless of seasonal pattern 1
• Computer or internet-based treatment can be used as an adjunct to pharmacotherapy or as a first-line treatment based on patient preference 1
• For patients on fluoxetine, the FDA label indicates that maintenance treatment for MDD can be maintained for periods up to 38 weeks following 12 weeks of open-label acute treatment 4
• Close monitoring for suicidality is essential, particularly during the initial few months of treatment or with dose changes, especially in children, adolescents, and young adults 4

Common Pitfalls to Avoid

• Failure to screen for bipolar disorder before initiating antidepressant treatment, which may precipitate mixed/manic episodes 4
• Premature discontinuation of antidepressant therapy, which increases risk of relapse 3
• Inadequate follow-up - all patients should be monitored on a monthly basis for 6-12 months after full resolution of symptoms 1
• Overlooking physical symptoms of depression (fatigue, pain, sleep disturbance) which may be the primary presenting complaints 5
• Treating depression as an acute rather than chronic condition, which requires long-term management strategies 5