What are the Indian Psychiatry Society guidelines for managing severe depression?

Management of Severe Depression: Evidence-Based Approach

Initial Treatment Strategy

For severe depression, combination treatment with both antidepressant medication and psychotherapy provides superior outcomes compared to either modality alone and should be initiated immediately. 1

Defining Severe Depression

Severe depression is characterized by:

• Presence of all or most DSM-5 depressive symptoms with severe intensity 2
• Specific suicide plan, clear intent, or recent attempt 2
• Psychotic features 2
• Severe functional impairment (unable to leave home or perform basic activities) 2
• First-degree family history of bipolar disorder 2

Pharmacological Management

First-Line Medication Options

Antidepressant medication should be initiated immediately in severe depression, with SSRIs (particularly fluoxetine) or second-generation antidepressants preferred as first-line agents due to their favorable safety profile. 3

• Tricyclic antidepressants (TCAs) may be considered but have less favorable safety profiles 3
• The drug-placebo difference for antidepressants shows a medium to large effect size in severe depression, unlike mild depression where the difference is minimal 2

Special Considerations for Severe Depression with Psychotic Features

When psychotic features are present, combination treatment with an antidepressant plus an antipsychotic medication is indicated. 2, 4

• Haloperidol or chlorpromazine should be offered as first-line antipsychotic options 2
• Second-generation antipsychotics may be alternatives if availability and cost permit 2

Monitoring Timeline

Assessment of treatment response must occur at specific intervals using validated instruments:

• Week 2: Initial response assessment and close monitoring for suicidality and behavioral activation 1, 3
• Week 4: If no response, increase SSRI dose to therapeutic equivalent 1
• Week 8: Comprehensive reassessment; if inadequate response, add evidence-based psychological intervention before medication changes 1

Regular monitoring (at 4 and 8 weeks) should assess symptom relief, side effects, adverse events, and patient satisfaction using standardized validated instruments. 2

Psychotherapy Integration

Evidence-Based Psychological Interventions

Cognitive behavioral therapy (CBT), interpersonal therapy (IPT), or problem-solving therapy should be initiated concurrently with medication in severe depression. 2, 1, 3

• CBT and IPT not only relieve acute distress but reduce risk for relapse/recurrence even after treatment discontinuation 5
• Individual therapy is preferred over group therapy for severe presentations 2
• Behavioral activation is an alternative evidence-based option 2

Treatment Response Monitoring for Psychotherapy

Mental health professionals should assess treatment response regularly (pretreatment, 4 weeks, 8 weeks, and end of treatment) using standardized measures. 2

Management of Inadequate Response

After 8 Weeks of Optimized Treatment

If inadequate response after 8 weeks despite good adherence, the treatment regimen must be adjusted:

• Add evidence-based psychological intervention to ongoing antidepressant (if not already combined) 2, 1
• Consider augmentation with bupropion SR 150-300mg daily or aripiprazole 2-15mg daily 1
• Switch antidepressant class if augmentation unsuccessful 2

Electroconvulsive Therapy (ECT)

ECT should be considered for:

• Severe psychotic depression 4
• Severe melancholic depression 4
• Treatment-resistant depression after multiple medication trials 4
• Patients with medical contraindications to antidepressants (renal, cardiac, or hepatic disease) 4
• Patients refusing or intolerant of medications 4

Treatment Duration and Maintenance

Antidepressant treatment must continue for a minimum of 9-12 months after achieving remission to prevent relapse. 1, 3

• Taper gradually rather than abrupt cessation to minimize discontinuation syndrome 1
• Maintenance treatment significantly delays recurrence in placebo-controlled trials 1

Patient and Family Education

Culturally informed and linguistically appropriate information must be provided to patients and caregivers, including:

• Commonality and frequency of depression 2
• Psychological, behavioral, and vegetative symptoms 2
• Signs of symptom worsening 2
• When and how to contact the medical team (with specific contact information) 2, 1

Critical Safety Considerations

Suicide Risk Management

Close monitoring for suicidal ideation and behavior is mandatory, particularly:

• During initial assessment 1
• In the first 1-2 months of antidepressant treatment 3
• At each follow-up visit (weeks 2,4, and 8) 1

Common Pitfalls to Avoid

• Do not use antidepressants as monotherapy without psychotherapy in severe depression - combination treatment is superior 1
• Do not delay treatment adjustments beyond 8 weeks if inadequate response - prolonged inadequate treatment increases morbidity 2, 1
• Do not stop antidepressants before 9-12 months after remission - premature discontinuation increases relapse risk 1, 3
• Do not use anticholinergics routinely with antipsychotics - only for significant extrapyramidal symptoms when dose reduction fails 2

Collaborative Care Implementation

Systematic follow-up and outcome assessment using collaborative care models significantly improve treatment effectiveness and should be implemented. 1