Not in United States? Choose your country's store to see books available for purchase. See if you have enough points for this item. Sign in. An estimated 21 million people are diagnosed each year with a major depressive disorder in the USA, Western Europe and Japan. The economic cost of depression and its impact on sufferers and those around them is enormous. There are numerous therapy choices available, which can be daunting for the clinician trying to achieve the best treatment regimen.
Managing Depression in Clinical Practice provides a concise overview of the clinical manifestation, diagnosis and management of this debilitating condition. The book gives practical coverage of depression in special populations, the management of treatment non-response and long-term treatment. Managing Depression in Clinical Practice is intended as an accessible text for family practitioners and psychiatrists in training and in practice. It will also be of interest to specialist nurses and allied health professionals working in the field.
A Family's Guide to Tourette Syndrome. Tourette Syndrome Association Inc. Joel L. Deborah J. Jess P. Stephen M. Practical Management of Bipolar Disorder. Allan H. Vulnerability to Psychosis. Paolo Fusar-Poli. Bipolar Disorder. Stephen Strakowski. The Neuroscience of Autism Spectrum Disorders. Joseph D. Essentials of Schizophrenia. Jeffrey A. Stahl's Self-Assessment Examination in Psychiatry. Marijuana and Madness. David Castle. Alcohol and Alcoholism.
Recognizing and Managing Depression in Primary Care A Standardized Patient Study
John H. Bipolar Depression. Rif S. Textbook of Anxiety Disorders. Dan J. Psychobiological Approaches for Anxiety Disorders. Stefan G. Principles and Practice of Psychopharmacotherapy. Philip G. Psychiatric Genetics. Jordan W. Lakshmi N. Clinician's Guide to Bipolar Disorder. David J. Mood Disorders and Antidepressants. The Origins of Schizophrenia. Alan Brown. Anxiety Disorders. Helen Blair Simpson. Green's Child and Adolescent Clinical Psychopharmacology.
William Klykylo. Raymond W. Ish P. Effective Treatments in Psychiatry. Peter Tyrer. Schizo-Obsessive Disorder. Michael Poyurovsky. Tobias Banaschewski. Deconstructing Psychosis. Carol A. Wolfgang Gaebel.
- The Strength In Us All.
- Clinical Practice Guidelines for the management of Depression.
Roger Freeman. Geriatric Depression.
Gary J. Andrew E. Kenneth S. Robert Hudak. Cognitive Dysfunction in Bipolar Disorder. Joseph F. The Maudsley Family Study of Psychosis. Colm McDonald. Clinical Manual of Palliative Care Psychiatry. Nathan Fairman. Steven R. Treating Child and Adolescent Depression. Joseph M.
Anthony J. Violence in Psychiatry. Katherine D. Injectable Fillers in Aesthetic Medicine. Mauricio de Maio. Neurobiology of Violence. Jan Volavka. Gabriel Stux. Jaswinder Ghuman. Clinical Handbook for the Management of Mood Disorders. John Mann. Robert D. A strong treatment alliance between patient and psychiatrist is crucial for poorly motivated, pessimistic depressed patient who are sensitive to side effect of medications.
A positive therapeutic alliance always generates hope for good outcome. The successful treatment of major depressive disorder requires adequate compliance to treatment plan. Patients with depressive disorder may be poorly motivated and unduly pessimistic over their chances of recovery with treatment. In addition, the side effect or requirements of treatment may lead to non-adherence. Patients are to be encouraged to articulate any concern regarding adherence and clinicians need to emphasize the importance of adherence for successful treatment.
Simple measures which can help in improving the compliance are given in table Many patients with depression experience relapse.
Clinical Practice Guidelines
Accordingly, patients as well as their families if appropriate may be educated about the risk of relapse. They can be educated to identify early signs and symptoms of new episodes. Patients can also be asked to seek adequate treatment as early in the course of a new episode as possible to decrease the likelihood of a full-blown relapse or complication. Treatment options for management of depression can be broadly be divided into antidepressants, electroconvulsive therapy ECT and psychosocial interventions.
Other less commonly used treatment or treatments used in patients with treatment resistant depression include repetitive transcranial magnetic stimulation rTMS , light therapy, transcranial direct stimulation, vagal nerve stimulation, deep brain stimulation and sleep deprivation treatment. In many cases benzodiazepines are used as adjunctive treatment, especially during the initial phase of treatment.
Additionally in some cases, lithium and thyroid supplements may be used as an augmenting agent when patient is not responding to antidepressants. Large numbers of antidepressants Table-6 are available for management of depression and in general all the antidepressants have been shown to have nearly equal efficacy in the management of depression.
Antidepressant medication may be used as initial treatment modality for patients with mild, moderate, or severe depressive episode. The selection of antidepressant medications may be based on patient specific and drug specific factors, as given in Table In general, because of the side effect and safety profile, selective serotonin reuptake inhibitors SSRIs are considered to be the first line antidepressants.
Other preferred options include tricyclic antidepressants, mirtazapine, bupropion, and venlafaxine. Usually the medication must be started in the lower doses and the doses must be titrated, depending on the response and the side effects experienced. 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 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. A specific, effective psychotherapy may be considered as an initial treatment modality for patients with mild to moderate depressive disorder.
Clinical features that may suggest the use of a specific psychotherapy include the presence of significant psychosocial stressors, intrapsychic conflict and interpersonal difficulties. Patient's preference for psychotherapeutic approaches is an important factor that may be considered in the decision to use psychotherapy as the initial treatment modality.
Pregnancy, lactation, orthe wish to become pregnant may also be an indication for psychotherapy as an initial treatment. Various psychotherapeutic interventions which may be considered based on feasibility, expertise available and affordability are shown in Table 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.
The psychiatrist should take into account multiple factors when determining the frequency of sessions for individual patients, including the specific type and goals of psychotherapy, the frequency necessary to create and maintain a therapeutic relationship, the frequency of visits required to ensure treatment adherence, and the frequency necessary to monitor and address suicidality. The frequency of outpatient visits during the acute phase generally varies from once a week in routine cases to as often as several times a week. Regardless of the type of psychotherapy selected, the patient's response to treatment should be carefully monitored.
For a given patient, time spent and frequency of visit may be decided by the psychiatrist. Education concerning depression and its treatments can be provided to all patients. When appropriate, education can also be provided to involved family members. Specific educational elements may be helpful in some circumstances, e. Education regarding available treatment options will help patients make informed decisions, anticipate side effects and adhere to treatments. Another important aspect of providing education is informing the patient and especially family about the lag period of onset of action of antidepressants.
Important components of psychoeducation are given in Table 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 treatments for patients receiving combined therapy. Management of depression can be broadly divided into three phases, i. Maintenance phase of treatment is usually considered when patient has recurrent depressive disorder. 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. In acute phase psychiatrist may choose between several initial treatment modalities, including pharmacotherapy, psychotherapy, the combination of medication and psychotherapy, or ECT. Selection of an initial treatment modality is usually influenced by both clinical e.
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. 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.
Dose and duration of antidepressants: Once an antidepressant medication has been selected, it can be started initially at lower doses and careful monitoring to be done to assess the response to pharmacotherapy as well as the emergence of side effects, clinical conditions, and safety. Factors to consider when determining the frequency of monitoring include severity of illness, patient's cooperation and presence with treatment, and availability of social support andpresence of comorbid general medical problems. Visits may be frequent enough to monitor and address suicidality and to promote treatment adherence.
If at least a moderate improvement is not observed in this time period, reappraisal and adjustment of the pharmacotherapy maybe considered. In the initial phase, depending on the symptom severity and type of symptoms, such as presence of insomnia or anxiety, benzodiazepines or other hypnotics may be used for short duration. If after 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.
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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. 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.
EVALUATE THE SAFETY OF PATIENT AND OTHERS
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. The major determinants of type of psychotherapy are patient preference and the availability of clinicians with appropriate training and expertise in specific psychotherapeutic approaches. Other clinical factors which will influence the type of psychotherapy include the severity of the depression.
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. The optimal frequency of psychotherapy may be based on specific type and goals of the psychotherapy, the frequency necessary to create and maintain a therapeutic relationship, the frequency of visits required to ensure treatment adherence, and the frequency necessary to monitor and address suicidality. Other factors which would also determine the frequency of psychotherapy visits include the severity of illness, the patient's cooperation with treatment, the availability of social supports, cost, geographic accessibility, and presence of comorbid general medical problems.
Besides the use of specific psychotherapy, all patients and their caregivers may receive psychoeducation about the illness. Role of Yoga and Meditation in management of depression: Studies related to role of traditional therapies like meditation, Yoga and other techniques have been mostly published in documents of various organizations propagating that particular technique. The goal of continuation phase is to maintain the gains achieved in the acute phase of treatment and prevent relapse of symptoms. The treatment algorithm to be followed is shown in figure Patients who have been treated with antidepressants in the acute phase need to be maintained on same dose of these agents for weeks to prevent relapse total period of month from initiation of treatment.
There are evidences to support the use of specific psychotherapy in continuation phase to prevent relapse. The use of other somatic modalities e. The frequency of visit during the continuation phase may be determined by patient's clinical condition as well as the specific treatment being provided. If maintenance phase treatment is not indicated for patients who remain stable following the continuation phase, patients may be considered for discontinuation of treatment. If treatment is discontinued, careful monitoring be done for relapse, and treatment to be promptly reinstituted if relapse occurs.
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The goal of maintenance phase treatment is to prevent recurrence of depressive episodes. Therefore, maintenance phase treatment may be considered to prevent recurrence. The duration of treatment may be decided keeping in view the previous treatment history and number of depressive episodes the person has had in the past.
Mostly the treatment that was effective for acute and continuation phase need to be used in the maintenance phase Figure Same doses of antidepressants, to which the patient had responded in previous phase is considered. There is no consensus regarding the duration and when to give and when not to give maintenance treatment. There is agreement to large extent that patients who have history of three or more relapses or recurrences need to be given long-term treatment. The decision to discontinue maintenance treatment may be based on the same factors considered in the decision to initiate maintenance treatment, including the probability of recurrence, the frequency and severity of past episodes, the persistence of depressive symptoms after recovery, the presence of comorbid disorders, and patient preferences.
When the decision is made to discontinue or terminate psychotherapy in the maintenance phase, the manner in which this is done may be individualized to the patient's needs. When the decision is made to discontinue maintenance pharmacotherapy, it is best to taper the medication over the course of at least several weeks to few months. Such tapering may allow for the detection of emerging symptoms or recurrences when patients are still partially treated and therefore can be easily returned to full therapeutic intensity.
In addition, such tapering can help minimize the risks of antidepressant medication discontinuation syndromes. Discontinuation syndromes have been found to be more frequent after discontinuation of medications with shorter half-lives, and patients maintained on short-acting agents may be given even longer, more gradual tapering.
Paroxetine, venlafaxine, TCAs, and MAOIs tend to have higher rates of discontinuation symptoms while bupropion-SR, citalopram, fluoxetine, mirtazapine, and sertraline have lower rates. The symptoms of antidepressants discontinuation include flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances e. If the discontinuation syndrome is mild, reassurance may be sufficient. If mild to moderate, short-term symptomatic treatment analgesics, antiemetics, or anxiolytics may be beneficial.
If it is severe, antidepressant are to be reinstated and tapered off more slowly. After the discontinuation of active treatment, patients should be reminded of the potential for a depressive relapse. Patient may be again informed about the early signs of depression, and a plan for seeking treatment in the event of recurrence of symptoms may be formulated. Patients may be monitored for next few months to identify relapse.
If a patient suffers a relapse upon discontinuation of medication, treatments need to be promptly reinitiated. In general, the previous treatment regimen to which the patient responded in the acute and continuation phase are to be considered.
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In some cases the apparent lack of treatment response is actually a result of faulty diagnosis, inadequate treatment, or failure to appreciate and remedy coexisting general medical and psychiatric disorders or other complicating psychosocial factors. Adequate treatment for at least weeks is necessary before concluding that a patient is not responsive to a particular medication.
First step in care of a patient who has not responded to medication is carrying out a thorough review and reappraisal of the psychosocial and biological information base, aimed at revarifying the diagnosis and identifying any neglected and possibly contributing factors, including the general medical problems, alcohol or substance abuse or dependence, other psychiatric disorders, and general psychosocial issues impeding recovery.
Algorithm for arriving at the diagnosis of treatment resistant depression is given in figure Some clinicians require two successive trials of medications of different categories for adequate duration before considering treatment resistant depression TRD. Algorithm for management of TRD is given in figure Addition of an adjunct to an antidepressant: Lithium is the drug primarily used as an adjunct; other agents in use are thyroid hormone and stimulants. Opinion differs as to the relative benefits of lithium and thyroid supplementation.
The interval before full response to adjunctive lithium is said to be in the range of several daysto 3 weeks. If effective and well tolerated, lithium may be continued for the duration of treatment of the acute episode. Thyroid hormone supplementation, even in euthyroid patients, may also increase the effectiveness of antidepressant treatment. Combinations of antidepressant carry a risk of adverse interaction and sometimes require dose adjustments. Another strategy involves combined use of a tricyclic antidepressant and a MAO inhibitor, a combination that is sometimes effective in alleviating severe medication-resistant depression, but the risk of serotonin syndrome necessitates careful monitoring.
Electroconvulsive therapy: Response to ECT is generally good and the response rates are like any form of antidepressant treatment and it may be considered in virtually all cases of moderate or severe major depression who do not respond to pharmacologic intervention. Lithium may be discontinued before initiation of ECT, as it has been reported to prolong postictal delirium and delay recovery from neuromuscular blockade. Repetitive transcranial magnetic stimulation rTMS; a type of TMS that occurs in a rhythmic and repetitive form has been put forward as a new technique to treat this debilitating illness.
Current evidence suggests that rTMS applied to the left dorsolateral prefrontal cortex DLPFC is a promising treatment strategy for depression, but not all patients show a positive outcome. Current clinical outcome studies report rather modest superiority compared with placebo sham. To date, it remains unclear which TMS parameters, such as stimulation duration and intensity, can produce the most benefits.