What are the management guidelines for depression?

Management Guidelines for Depression

As a psychiatrist managing depression, you should implement a systematic approach that includes comprehensive assessment with structured diagnostic interviews, severity classification using validated tools, establishment of a safety plan with lethal means restriction, patient/family psychoeducation, and evidence-based treatment selection based on severity—with CBT or SSRIs as first-line options for moderate-to-severe depression, active monitoring for mild cases, and combination therapy for severe or treatment-resistant presentations. 1, 2

Initial Assessment and Diagnosis

Conduct direct clinical interviews with both patients and families/caregivers to establish diagnosis using DSM-5 criteria, requiring at least 5 symptoms over 2 weeks including depressed mood or anhedonia 3, 2. Do not rely solely on screening tools—they aid diagnosis but cannot replace clinical interview 3.

Key Assessment Components:

• Assess functional impairment across multiple domains: school/work, home, and peer/social settings 3
• Screen for comorbid psychiatric conditions including anxiety disorders, substance use disorders, and bipolar disorder risk (obtain detailed psychiatric and family history of suicide, bipolar disorder, and depression) 3, 4
• Evaluate suicide risk in every patient regardless of severity—this is non-negotiable 3
• Use standardized assessment tools: PHQ-9, HAM-D, MADRS, or QIDS-SR to quantify severity and track treatment response 2

Severity Classification:

• Mild: 5-6 symptoms with mild severity and minimal functional impairment 3, 1
• Moderate: Between mild and severe 3, 1
• Severe: All DSM-5 symptoms present, OR severe functional impairment, OR presence of suicide plan/intent/recent attempt, OR psychotic symptoms, OR first-degree family history of bipolar disorder 3, 1

Safety Planning (Mandatory for All Patients)

Establish a comprehensive safety plan immediately that includes: 3

• Restrict access to lethal means (firearms, medications, other methods)
• Engage a concerned third party (family member, friend) who can monitor the patient
• Develop emergency communication mechanism for acute crises, suicidality, or clinical deterioration
• Monitor most closely during initial treatment period when safety concerns are highest 3

Patient and Family Psychoeducation

Provide education about depression as a recurring condition with expected treatment outcomes, causes, symptoms, and associated impairments at a developmentally appropriate level 3. Discuss limits of confidentiality, including mandatory disclosure when imminent harm to self or others exists 3.

Treatment Selection Based on Severity

Mild Depression:

Consider active monitoring ("watchful waiting") as initial approach for mild depression 1, 5. If symptoms persist or worsen, initiate CBT alone as first-line treatment 2, 5. CBT has equivalent effectiveness to antidepressants with moderate-quality evidence 2.

Moderate Depression:

Offer either CBT or second-generation antidepressants (SSRIs/SNRIs) as first-line treatment—both have similar effectiveness 1, 2, 6. Selection should be based on adverse effect profiles, cost, and patient preference 2.

First-line antidepressant options include: 1, 2, 6

• SSRIs (fluoxetine, sertraline, escitalopram, citalopram, paroxetine)
• SNRIs (venlafaxine, duloxetine)

Evidence-based psychotherapy options include: 1, 6

• Cognitive Behavioral Therapy (CBT)
• Interpersonal Psychotherapy (IPT)
• Behavioral Activation
• Problem-Solving Therapy
• Brief Psychodynamic Therapy
• Mindfulness-Based Psychotherapy

Severe Depression:

Initiate combination treatment with both antidepressant medication AND psychotherapy—this approach shows superior outcomes compared to either modality alone (SMD 0.30-0.33 greater improvement) 1, 6. For severe depression with psychotic features, consider adding an atypical antipsychotic 5.

Treatment Monitoring and Adjustment

Assess treatment response within 1-2 weeks of initiation, monitoring for therapeutic effects, adverse effects, and suicidality 2, 4. All patients on antidepressants must be monitored closely for clinical worsening, suicidality, and unusual behavioral changes, especially during initial months and after dose changes 4.

Warning Signs Requiring Immediate Attention:

Monitor for anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, or mania—these may be precursors to emerging suicidality 4.

If Inadequate Response by 6-8 Weeks:

Modify treatment approach by: 1, 2

• Adjusting dose to maximum tolerated level
• Switching to different antidepressant class
• Adding second antidepressant
• Augmenting with non-antidepressant medication (e.g., atypical antipsychotic)
• Adding evidence-based psychotherapy if not already included 1

Explore causes of partial response: 1

• Poor medication adherence
• Comorbid disorders not adequately treated
• Ongoing conflicts, stressors, or abuse
• Inadequate dose or duration of trial

Treatment-Resistant Depression:

Consider mental health consultation if no improvement after two adequate pharmacologic trials (sufficient dose and minimum 4 weeks duration) 1, 2. For confirmed treatment-resistant depression, repetitive transcranial magnetic stimulation (rTMS) may be considered 1.

Continuation and Maintenance Treatment

Continue antidepressant treatment for 6-12 months after full symptom resolution to prevent relapse 1, 2. For recurrent depression (≥2 episodes), extend maintenance treatment to ≥1 year or longer 1, 2.

Monitor all patients monthly for 6-12 months after achieving remission—inadequate follow-up is a common pitfall leading to relapse 1.

Collaborative Care and Referral

Develop clear roles and responsibilities between primary care and mental health providers when co-managing cases 1. Actively support patients referred to mental health services to ensure treatment engagement 1.

Consider psychiatric consultation for: 1

• Treatment-resistant depression (failed 2+ adequate trials)
• Severe depression with psychotic features
• High suicide risk
• Diagnostic uncertainty (especially bipolar disorder screening)
• Complex comorbidities

Adjunctive Treatment Options

Bright light therapy is recommended for mild-to-moderate depression regardless of seasonal pattern 1. Computer or internet-based treatment can be used as adjunct to pharmacotherapy or first-line treatment based on patient preference 1.

Critical Pitfalls to Avoid

• Inadequate dosing or premature discontinuation before therapeutic effects achieved (typically 4-6 weeks minimum) 2
• Failure to continue treatment long enough to prevent relapse (minimum 4-9 months after response) 2
• Not screening for bipolar disorder before initiating antidepressants—treating bipolar depression with antidepressants alone may precipitate manic episodes 4
• Inadequate suicide risk monitoring, especially during initial treatment and dose changes 2, 4
• Abrupt discontinuation of antidepressants—taper gradually to avoid discontinuation syndrome 4
• Missing comorbid substance use disorders—these require integrated concurrent treatment, not sequential management 7

Special Considerations for Comorbid Conditions

For comorbid alcohol use disorder and depression, use integrated care approach treating both conditions concurrently with same treatment team 7. Consider SSRIs/SNRIs for depression plus FDA-approved medications for alcohol use disorder (naltrexone, acamprosate, or disulfiram) 7. CBT has strong evidence for both conditions 7.