The following document was written by Dr Vipul Rastogi, MBBS; DCP (Ireland); MRCPsych (UK) Speciality Registrar, Hampshire Partnership Trust, UK, March 2008.
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Treatment of Major Depression

Before contemplating treatment, you should have full history of the patient along with fairly comprehensive physical examination. You should have also completed relevant investigations and completed your risk assessment. Your risk assessment will guide you as to in which setting you would like to treat the patient, i.e. community, under home treatment team or in hospital. The risk of attempting suicide would also govern your choice and amount of anti depressants you prescribe.

The treatment of depression should follow a Stepped Care Model. Assessment and Diagnosis of Depression is usually carried out by GP or the Practice Nurse. Thereafter, the services availability varies in various parts of the country. Some surgeries have primary mental health workers attached to them and they help and guide treatment.

Mild to moderate depression is generally treated by the GP in primary care and the severe depression clients treated in secondary or tertiary care.

There are largely two categories of treatment options available.

1 - Biological

2 - Psychological

Readers should note that the above mentioned treatment modalities are only the most common options used, for more information they should read a standard textbook.

Mild Depression

Antidepressants are not advocated as the risk-benefit ratio is poor.

A watchful waiting is advised but it might be necessary to provide counseling or problem solving therapy.

The patients can also be offered computerized CBT with self help guides.

Info on sleep hygiene, anxiety and substance misuse might also be important.

The patient should be regularly followed up to see signs of improvement or deterioration in mood and risk assessment undertaken each time.


Moderate Depression

An antidepressant should be started. The choice of antidepressant depends on patient characteristics i.e. physical health, risk of suicide, substance misuse, adverse events and foremost patient choice/preference.

Generally SSRI (Selective Serotonin Uptake Inhibitors) like Fluoxetine or Citalopram are first line drugs and safe with regards to frequency of side effects and in overdose.

Patients should be monitored regularly for side effects, deterioration of mood and suicidal ideation. They should always be seen within one week of starting antidepressants and risk assessment should be undertaken every time.

It would be useful to give patients information about sleep hygiene, anxiety management and substance misuse.

If patients do not respond to the initial antidepressant than another antidepressant from the same class or from other class should be used.

Tricyclic Antidepressants are one of the oldest classes of antidepressants available and there use has gone down in recent years because of their side effects and toxicity in overdose but having said that they are quite effective.

Other options are the relatively new antidepressants like Mirtazapine, Reboxetine, Lofexidine or Venlafaxine.

Psychological Therapies are also an important component of treatment and CBT and IPT should be provided by trained health care professional for a period of at least 6 months.


Severe Depression

Severe depression can be treated in primary care but mostly it is treated in secondary care as outpatient or in tertiary care by home treatment team or as an inpatient depending on the risk.

The best evidence is for use of both pharmacological and psychological treatments together.

The pharmacological treatment follows the same principles as in moderate depression with use of SSRI to start with and moving to other classes of antidepressant if there is no response. In cases of agitated depression a short course of tranquilizers might be particularly useful initially.

Keep an eye on the food and fluid intake along with suicidal ideation in the patient. Never prescribe more than a week to two weeks prescription of medication at one time.

Psychological treatment would consist of CBT provided by a trained health care professional for at least 6-9 months.


Resistant Depression

If the depression has not responded to an adequate dose of antidepressant then investigate non compliance or any co morbid substance misuse. Also look at any social factors like relationship or financial difficulties hampering improvement and help should be provided in these areas.

If the patientís condition is deteriorating and there is psychomotor retardation and the patient is not eating or drinking, you should discuss it with your supervisor as this is an emergency and ECT might be one of the options.

Also investigate any physical causes like any occult malignancies, space occupying lesions in brain, chronic pain, hypothyroidism, diabetes and adrenal gland pathology complicating the picture.

If you are sure that none of the above is there than augmenting the antidepressant with another antidepressant, Lithium, Sodium Valproate or an antipsychotic in low dose can be useful.

I have specifically not gone into details of augmentation as all patient characteristics are different and you should discuss and get supervision from your clinical supervisor about the augmentation they prefer, possible side effects and patient choice.

Treatment of depression in special populations

Depression in Young People

Depression in children and adolescents should be treated by specialist CAMHS services.

Antidepressants as a rule are not advocated for this population. The main treatment modalities are psychological including family therapy and CBT. Social issues like family discord, abuse and bullying may be the main precipitating and perpetuating factors.

In severe depression only after CBT has been tried and there has been no response Fluoxetine may be tried.


Depression in Older Age Persons

Depression in old age usually follows the same principles as adults. You have to be more mindful of side effects and therefore generally lower doses are used. You also have to be more mindful of an underlying physical disorder or dementia leading up to the depression. They need more social care input as well and treatment should always be on multi disciplinary lines.


Depression in Pregnancy

Depression is not uncommon in pregnancy and it is very useful to follow a multidisciplinary approach with midwives, obstetrician and pediatricians also involved. There has to be a full discussion with the patient about risks to the fetus and also about medication during breast feeding and these should be documented in notes in as much detail as possible.

For mild and moderate depression psychological treatments like CBT/ IPT should be used. If there is no response or patient refuses than antidepressants like fluoxetine or amitryptiline can be used. TCAís like amitryptiline or imipramine have the lowest teratogenic potential but are more toxic in overdose.

In breast feeding patients sertraline and imipramine have lower concentration than other antidepressants.


Depression and Cardiac Impairment

SSRIís like Fluoxetine and Citalopram are generally considered safe in this population. Tricyclic Antidepressants should be avoided. Please do see product literature and get advise from your clinical supervisor and cardiologists if in doubt.


Depression and Renal Impairment

Fluoxetine and Citalopram would probably be the drugs of choice. As always see product literature and consult with senior colleagues when initiating treatment. Regular monitoring of renal functions will be important.


Depression and Hepatic Impairment

Will need to use lower doses of anti depressants with careful monitoring of liver functions and side effects. You need to get advise from senior colleagues before initiating treatment. Do also look out for co morbid alcohol misuse.


Authors Note- These guidelines are only recommendations based on current evidence base and on authors experience. You are highly recommended to read a standard textbook and get advise from your senior colleagues if you are not sure as all patients have different needs and your choices will also depend on service availability in your locality.


Author:


Dr Vipul Rastogi, MBBS; DCP (Ireland); MRCPsych (UK)

speciality Registrar, Hampshire Partnership Trust, UK



References:

1) NICE guidelines on Depression- April 2007

2) NICE guidelines on Depression in Young People- September 2005

3) NICE guideline on Antenatal and Postnatal Mental Health- April 2007

4) Essential Psychopharmacology- The Prescriberís Guide- Stephen Stahl






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