- The key objectives of treatment are:
- Acute phase goal for treatment of depression is total symptom remission. This necessitates some measurement of symptom severity at critical decision points during and at the end of treatment to determine whether remission has been attained.
- Reduction of recurrence of depression and panic disorder.
- Return to previous level of occupational and psychosocial function.
- Treatment Considerations
- Pharmacologic Therapy vs. Psychotherapy
- Pharmacologic and/or non-pharmacologic interventions (psychotherapy) are effective in treating both depression and anxiety disorders. Patient preferences should be considered. Factors to consider in making treatment recommendations are symptom severity, presence of psychosocial stressors, presence of co-morbid conditions, and patient preferences.
- Depression treatment should take health beliefs into account. Patients who perceive more self-control of their health experienced greater reduction in depression symptoms, whether treated with psychotherapy or an antidepressant. Therefore, it is important to adequately assess a patient's expectations and beliefs in the controllability of depressive symptoms and functioning in order to treat depression effectively and to minimize the risk of relapse and recurrence.
- Pharmacologic Therapy
- Treatment of choice for major depression may include pharmacology and psychotherapy. For patients with mild to moderate depression, psychotherapy and/or pharmacology is indicated. For severe depression, a combination therapy is indicated
- If the initial medication response is incomplete after six weeks at therapeutic dose (e.g., partial positive response to medication), add or substitute another treatment modality.
- When considering how long to continue medication after remission of acute symptoms, two issues need to be considered: Continuation and Maintenance treatment.
Acute Phase involves stabilization of acute symptoms (usually 3 months).
Continuation treatment (usually lasting 6-12 months after the acute treatment) consists of prolonged administration of treatment after disappearance of acute depressive symptoms and aims to maintain an euthymic state or a duration of the episode.
Maintenance treatment consists of long-term efforts to prevent new episodes of recurrences and can extend for years. It should be strongly considered for all patients at the risk of recurrence. (Refer to original guideline document for risk factors for recurrence.)
Continuation treatment and Maintenance Treatment should consist of full dose antidepressant therapy. The recommended guidelines for treatment of depression are as follows:
First Episode – Treatment duration up to 1 year
Second Episode – Treatment duration of 4-5 years
Second Episode with Complicating Factors – Indefinite treatment duration
Third Episode – Indefinite treatment duration
Providers and patients often have strong opinions regarding the use of certain medications such as benzodiazepines, or whether to rely on psychotherapy or medication. Offer patients a menu of effective treatments. Medications and/or cognitive behavioral treatments may be effective for panic disorder and generalized anxiety disorder. Benzodiazepines and Selective Serotonin Re-uptake Inhibitors (SSRIs) have proven efficacy for panic disorder.
- Outcome studies support the efficacy of various psychotherapeutic approaches (cognitive-behavioral, interpersonal, structured educational group therapy).
- Consider early referral for psychotherapy if psychological and psychosocial issues are prominent and/or patient requests it. Referral for psychotherapy may have maximum benefit as symptom severity diminishes.
- Supportive therapy by the physician in the primary care setting is not the same as a course of psychotherapy with a mental health professional. However, education, support and reassurance by the physician are critical. Support/reassurance includes asking the patient for his/her ideas regarding the cause of the depression, anxiety or the panic, and about their expectations of recovery Ask patients with panic attacks "What is your greatest fear?" Do not accept "I don't know." The most common fears are physical (fainting or death from stroke, heart attack or suffocation) and psychological (embarrassment, humiliation or going crazy). Reassure patients that anxiety attacks are not dangerous. Inform patients with depression that they have a good chance of improving with an antidepressant.
Physical activity is a useful tool for easing depression symptoms. Among individuals with major depression, exercise therapy is feasible and is associated with significant therapeutic benefit, especially if exercise is continued over time. When prescribing exercise as an adjunct to medication and psychotherapy, the complexity and the individual circumstances of each patient must be considered. (See original guideline for several caveats that apply when prescribing exercise.)
- Patient Education
- Successful care of depression requires tailored and on-going patient education, beginning at the time of diagnosis. Written materials are helpful to reinforce information shared during the discussion. Patients who receive this education compared with those who do not are more likely to continue, rather than prematurely abandon treatment, and are more likely to attain better outcomes. Education topics should include:
- The cause, symptoms and natural history of major depression
- Treatment options (trial and error approach)
- Information on what to expect during the course of treatment
- The importance of compliance with medication regimens
- How to monitor symptoms and side effects
- Follow-up regime (office visits and/or telephone contacts)
- Early warning signs of relapse or recurrences
- Length of treatment
- When antidepressant therapy is prescribed, the following key messages should be highlighted to support medication compliance and completion:
- Most people need to be on medication at least 6 months.
- It may take from 1-6 weeks before improvement is seen.
- Take the medication as prescribed.
- Do not stop taking the medication without calling your provider. Side effects can be managed by changes in the dosage or dosage schedule.
Selective Serotonin Reuptake Inhibitors (SSRI's) and Tricyclic Antidepressants (TCA's)
SSRIs and TCAs are frequently chosen as first-line therapy because of simplicity, side effect profiles and community standards.
For antidepressant medications, adherence to a therapeutic dose and meeting clinical goals are more important than the specific drug selected. The educational messages in Algorithm Appendix A of the original guideline may increase compliance.
Benzodiazepines are effective for generalized anxiety disorder and panic disorder. The benzodiazepines are not identical with regard to potency, onset and duration of action or presence of active metabolites; therefore if a patient's response is less than optimal, try a different drug. Benzodiazepines with long half lives or active metabolites are more convenient to administer but may cause toxicity in older patients or patients with liver disease.
Benzodiazepines as a class have a small potential for abuse and physical dependency addiction is rare in patients with no history of drug or alcohol abuse. Screen for past or present chemical dependency and use benzodiazepines with care, if at all, with chemically dependent patients.
Patients on long-term benzodiazepines are usually taking lower rather than higher doses after years of treatment. Some clinicians consider benzodiazepines only for short-term use, or when other drugs have failed to control symptoms, or have significant side-effects. Research data do not support forbidding or continuing the long-term use of benzodiazepines.
When evaluating patients for long-term treatment with benzodiazepines, consider using the following Dupont criteria and document the continued appropriate use of the drug. If you can answer yes to the following questions, it is reasonable to document answers and continue treatment:
- Does the problem being treated justify continued benzodiazepine treatment? Has the patient significantly benefited from treatment?
- Is the use of benzodiazepines within reasonable limits? Has use been stable over time? Has the patient avoided use of other prescription or non-prescription substances?
- Has the patient been free of toxic symptoms, side effects or impairments from benzodiazepine use?
- Are the above confirmed by a family member who can monitor the patient?
Refer to the original guideline document for detailed treatment considerations, educational messages and dosage recommendations.
Evidence supporting this recommendation is of classes: A, C, D, M, R
Hypericum perforatum (St. John's wort), an herbal remedy marketed as a dietary supplement, appears to be more effective than placebo and as effective as low-dose tricyclic anti-depressants for the treatment of mild depression. It appears better tolerated, especially in the elderly or for patients with cardiac conductive abnormalities. It may be as effective as selective serotonin re-uptake inhibitors for mild to moderate depression in some patients. It may also have a place as an initial treatment for moderate depression, and may be effective for seasonal affective disorder (SAD.) St. John's wort does not appear to be effective for the treatment of major depression. Side effects appear to be infrequent and mild, headache being most common (41% v 25% for placebo).
Herbal products and nutritional supplements are not evaluated or regulated by the U.S. Food and Drug Administration for safety, efficacy or bioavailability. Caution: many drugs interact with St. John's wort, including other anti-depressants, warfarin, oral contraceptives, antiretroviral, anti-cancer and anti-rejection drugs. Care should be taken to ask all patients what medications they are taking including over the counter and supplements to avoid these interactions.
Other herbal remedies, such as kava-kava or valerian root, have not been proven effective for the treatment of depression.
Initial Follow-up Contact Intervals (office, phone, other)
- One to four weeks after initiation of medication, depending on symptom severity.
- If treatment is going well, follow-up every one to two months until patient is stable, then every three to six months.
- If treatment is not going well after four to six week medication trials at a therapeutic dose of one or two medications, re-evaluate the diagnosis, then consider referral to Psychiatry.
Length of initial treatment and follow-up:
Depression: Unless maintenance treatment is planned, antidepressant medication is discontinued at four to nine months after complete remission, and tapered over several weeks.
Consider life-long maintenance treatment if three or more episodes of major depression.
Anxiety: Although anxiety disorders are often chronic, there are no research studies evaluating long-term treatment. Three to six months is a reasonable length of initial treatment. Follow the patient for at least another six to 12 months to ascertain that key objectives of treatment are maintained. If key objectives are not maintained, review treatment options with the patient. If anxiety symptoms recur after two careful medication tapers, consider lifetime maintenance.
Office visits for maintenance medication can occur every six to 12 months.
Consider involvement of a mental health provider for the following:
- Presence of severe symptoms and impairment in patient.
- Diagnostic question.
- Presence of other psychiatric condition (e.g., personality disorder, history of mania).
- Chemical dependency questions.
- Clinician discomfort with the case.
- Initial treatment does not result in a successful outcome.
- Patient's request for more specialized treatment.