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ErkkiIsometsä

Planning the Treatment of Patients with Depression

Essentials

  • Assess the severity of the depression (mild/moderate/severe/psychotic) because the setting and mode of management is largely determined by this. Mild depression should always and moderately severe depression in most cases be treated in primary health care.
  • Assess the risk of suicide and refer severely suicidal patients for specialized psychiatric care (in case of immediate risk arrange voluntary or involuntary hospitalization) A Patient at Risk of Suicide.
  • Assess functional capacity, coping at work and at home, and the need for sick leave, supportive measures or hospitalization.
  • Find out how many depressive episodes the patient has had during his/her lifetime, as this is decisive for assessing the need for long-term maintenance treatment.
  • In the acute phase, the use of both antidepressant medication and psychotherapy is usually justified. The best results are often obtained by combining these Psychological Therapies for Treatmentresistant Depression in Adults.
  • For the individual treatment plan, the patient's needs, available effective forms of treatment and other supportive measures should be considered Collaborative Care for Depression and Anxiety Problems.

Diagnosis

Basis of the treatment plan, and staging of treatment

  • The individual treatment plan depends on the following, in particular:
    • current severity of depression
    • severity of prior episodes of depression
    • psychiatric comorbidity
    • suicide risk
    • functional capacity
    • somatic health
    • previous responses to treatment
    • patient's wishes for treatment.

Staging the treatment of depression

Primary health careOutpatient psychiatric carePsychiatric hospital
Mild or moderate acute depressionSevere depressionPsychotic depression
Moderate depression and severe comorbiditySerious risk of suicide
Self-destructive behaviourSevere depression and incapacity
Treatment-resistant depression
Depression and long-term (> 2 months) inability to work
  • For staging of treatment, see Table T1.
  • Mild depression and most cases of moderately severe depression should be treated in primary health care.
  • Consult a specialist, if:
    • the patient is in danger of suicide
    • there are problems with diagnosis or pharmacotherapy
    • there are severe problems in cooperation with the patient
    • incapacity for work threatens to last for more than 2 months
    • bipolar disorder is suspected
    • starting long-term maintenance treatment is considered
    • psychotherapeutic treatment is considered necessary.
  • Refer patients to specialized psychiatric care if they have:
    • severe or psychotic depression
    • moderately severe depression with severe psychiatric comorbidity
    • severe suicidal thoughts.
  • Refer patients to a psychiatric hospital, immediately and involuntarily if needed, if they have severe or psychotic depression and
    • are unable to take care of themselves
    • are at immediate risk of suicide (such as having severe suicidal thoughts or plans) or
    • are incapable of cooperation because of depression or other severe psychiatric cause.
  • Ensure treatment until the patient is in specialized care because especially the transfer phases are dangerous considering e.g. the risk of suicide.
  • When needed, organize social support in cooperation with social services.
  • Occupational health services play an essential role in supporting the return to work.

Choice of treatment Exercise for Depression, Acupuncture for Depression, Music Therapy for Depression, Collaborative Care for Depression and Anxiety Problems

  • The treatment of depression is divided into three phases:
    1. Acute phase aiming at eliminating the symptoms.
    2. Further treatment phase aiming to prevent the recurrence of symptoms.
    3. Maintenance treatment, which is only needed for patients whose depressive episodes have already recurred. The aim is to prevent further disease episodes.
  • The treatment of acute depression may include:
    • psychotherapy that has proved to be effective
    • antidepressants, or
    • both at the same time, which is usually the most effective form of treatment Psychological Therapies for Treatmentresistant Depression in Adults.
    • Other alternatives include:
      • electroconvulsive therapy (ECT) for severe or psychotic depression
      • transcranial magnetic stimulation (TMS)
      • transcranial direct current stimulation (tDCS)
      • bright light therapy for winter depression (seasonal affective disorder).
  • Patients with depression evidently benefit from regular physical exercise in groups Exercise for Depression.
  • The choice of treatment depends on the severity of depression (Table T2). The more severe the depression, the more significant the role of pharmacotherapy. In mild to moderate depression, antidepressants and psychotherapy are equally effective.
  • Remote or online therapy can also be used.
  • Monitor the patient's condition and treatment response every 1 to 3 weeks until the patient no longer has symptoms and the acute phase is over.
  • If depression requires sick leave it also requires active treatment and follow-up.

Severity of depression and choice of acute phase treatment

TreatmentMildModerateSeverePsychotic
Internet-mediated IT-assisted therapies (online therapies)++--
Psychotherapies++(+)-
Antidepressants (see also Pharmacological Treatment of Depression)++++
Concomitant antidepressant and antipsychotic medication---+
Electroconvulsive therapy (ECT)--++

Treatment of the acute phase

Treatment with antidepressants

  • There are no clinically significant differences in efficacy between the different antidepressant groups but there are differences in adverse effects. Treatment responses and adverse effects vary individually.
  • Monitor the patient's condition and treatment response every 1 to 3 weeks during the whole acute phase. Use symptom questionnaires (PHQ-9, BDI) to monitor the response.
  • If after 2-4 weeks no clear initial response has been obtained with the initial dose (> 20% decrease in symptom score), raise the dose to at least the usual therapeutic level.
  • Change to another drug if no clear treatment response (> 50% decrease in symptom score) can be observed within 6-12 weeks.
  • Inform the patient and the family sufficiently about depression, its course and treatment.
  • If two appropriate therapeutic attempts have not produced a response, the patient has what is called drug-resistant depression and a psychiatrist should be consulted.

Psychotherapy Behavioural Versus other Psychological Therapies for Depression, Psychological Therapies for Treatmentresistant Depression in Adults

  • Psychotherapy is used particularly in mild and moderate depressive disorders.
  • National or regional variation in the availability may be a problem.
  • The patient must be motivated and willing to commit to regular weekly work. The need for therapy and the patient's suitability for it should be evaluated by a psychiatrist.
  • The main forms of brief psychotherapy are:
    • cognitive psychotherapy (see Cognitive Psychotherapy)
    • interpersonal psychotherapy
    • behavioural activation
    • brief psychodynamic psychotherapy.
  • For mild depression, the following types of therapy can also be used:
    • problem-solving therapy
    • solution- or resource-focused therapy
    • acceptance and commitment therapy.
  • Primary health care physicians can also refer patients for brief interventions in primary health care, if available.

Electroconvulsive therapy (ECT)

  • Can be used in severe and psychotic depressive disorders especially if there is an immediate risk of suicide.
  • Given under anaesthesia, usually in connection with psychiatric inpatient treatment.
  • More effective than pharmacotherapy.

Bright light therapy and neuromodulation

  • Has been shown to be effective in winter depression (seasonal affective disorder).
  • Bright light at an intensity of 2500 lux should be given for 30-60 minutes.
  • The effect can be evaluated after a period of treatment of approximately one week.
  • Transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) can be used alternatively particularly in cases where ordinary forms of treatment are unsuitable.

Further treatment

  • Continue the medication for 6 months after the patient has become symptomless and end the treatment by tapering down over a period of a few weeks.
  • Withdrawal symptoms may occur when ending treatment with antidepressants, particularly some SSRIs (paroxetine, in particular) or venlafaxine. In that case, return to the preceding dose level and taper off the medication carefully in small steps over several months.
  • Advise the patient about the risks of recurrence and inform him/her how to seek care.

Maintenance treatment

  • If the patient has had recurrent episodes of moderate or more severe depressive disorder, after the third episode, at the latest, consider long-term maintenance treatment for several years. Consult a psychiatrist on the need for long-term maintenance therapy.
  • Maintenance treatment will require follow-up visits at intervals of no more than one year.
  • After several years without symptoms, tapering off of maintenance treatment may be considered. Taper off the medication carefully over several months. If disturbing withdrawal symptoms occur, proceed as described for ending further treatment.