Introduction to DepressionDepression (major depressive disorder, MDD) is widely recognised as a major public health problem around the world. The mainstay of treatment is the prescription of antidepressants, although psychological treatments have a place as a first-line alternative to antidepressants in milder and moderate forms of depression.1 Other methods of treating depression (vagal nerve stimulation [VNS],2 repetitive transcranial magnetic stimulation [rTMS],3, 4 transcranial direct current stimulation,3 etc.) are also used but are not widely available.
The basic principles of prescribing are described in Table 3.1, together with a summary of National Institute for Health and Care Excellence (NICE) guidance.
Table 3.1 Basic Principles of Prescribing in Depression.
- Discuss with the patient choice of drug and utility/availability of other, non-pharmacological treatments.
- Discuss with the patient likely outcomes, such as gradual relief from depressive symptoms over several weeks.
- Prescribe a dose of antidepressant (after titration, if necessary) that is likely to be effective.
- Assess the treatment's efficacy within 2-4 weeks of initiation (sooner in young people).
- Monitor treatment adherence and inform the patient about the risk of withdrawal symptoms.
- Monitor for adverse effects.
- For a single episode, continue treatment for at least 6 months after resolution of symptoms. Multiple episodes or high-risk patients may require longer; continuing treatment may reduce the risk of relapse.
- For patients continuing treatment, review treatment every 6 months.
- Withdraw antidepressants very gradually; always inform patients of the risk, duration and nature of discontinuation symptoms.
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