Clinical Practice Guidelines for the management of Depression

Participants of expert group on CPG for Depression Gautam Saha, I.D Gupta, Navendu Gaur, Tushar Jagawat, Anita Gautam, T. S Sathyanarayana Rao INTRODUCTION Depression is a common disorder, which often leads to poor quality of life and impaired role functioning. It is known to be a major contributor to the global burden of diseases and according to World Health Organization (WHO), depression is the fourth leading cause of disability worldwide and it is projected that by 2020, it will be the second most common leading cause of disability. Depression is also associated with high rates of suicidal behaviour and mortality. When depression occurs in the context of medical morbidity, it is associated with increased health care cost, longer duration of hospitalization, poor cooperation in treatment, poor treatment compliance and high rates of morbidity. Depression is also known to be associated with difficulties in role transitions (e.g., low education, high teen child-bearing, marital disruption, unstable employment) and poor role functioning (e.g., low marital quality, low work performance, low earnings). It is also reported to be a risk factor for the onset and persistence of a wide range of secondary disorders. Available data also suggests that between one-third and one-half of patients also experience recurrence of depressive episodes. ASSESSMENT AND EVALUATION (table-1)Table 1: Components of assessment and evaluationManagement of depression involves comprehensive assessment and proper establishment of diagnosis. The assessment must be based on detailed history, physical examination and mental state examinations. History must be obtained from all sources, especially the family. The diagnosis must be recorded as per the current diagnostic criteria. Depression often presents with a combination of symptoms of depressed mood, loss of interest or pleasure, decreased energy and fatigue, reduced concentration and attention, reduced self-esteem and self-confidence, ideas of guilt and unworthiness, bleak and pessimistic views of the future, ideas or acts of self-harm or suicide, disturbed sleep and diminished appetite. Depending on the severity of depression some of these symptoms may be more marked and develop characteristic features that are widely regarded as having special clinical significance. These symptoms are known as somatic symptoms of depression and include symptoms of loss of interest or pleasure in activities that are normally enjoyable, lack of emotional reactivity to normally pleasurable surroundings and events, waking up in the morning 2 hours or more before the usual time, depression worse in the morning, objective evidence of definite psychomotor retardation or agitation (remarked on or reported by other people), marked loss of appetite, weight loss (often defined as 5% or more of body weight in the past month) and marked loss of libido. It is important to note that for the diagnosis of depressive disorder these symptoms need to be present for at least 2 weeks and need to be associated with psychosocial dysfunction. Some of the patients with depression may present with predominant complaints of aches, pains and fatigue and they may not report sadness of mood on their own. A careful evaluation of these patients often reveals the underlying features of depression. However, it is important to note that many patients with depression will also have associated anxiety symptoms. With increasing severity of depression patients may report psychotic symptoms and may also present with catatonic features. Thorough assessment also ought to focus on evaluation for comorbid substance abuse/dependence. Careful history of substance intake need to be taken to evaluate the relationship of depression with substance intoxication, withdrawal and abstinence. Whenever required appropriate tests like, urine or blood screens (with prior consent) may be used to confirm the existence of comorbid substance abuse/dependence. Many physical illnesses are known to have high rates of depression. In some situations the physical illnesses have causative role in development of depression, whereas in other situations the relationship/co-occurrence is due to common etiology. Some of the physical illnesses commonly associated with depression are listed in Table-2. When depression occurs in relation to physical illness attempt may be made to clearly delineate the symptoms of depression and physical illness. Further, while making the diagnosis, it maybe clearly mentioned as to which diagnostic approach i.e., inclusive approach (symptoms are counted whether or not they might be attributable to physical illness), substitute approach (nonsomatic symptoms are substituted with somatic symptoms), exclusive approach (somatic symptoms are deleted from the diagnostic criteria) or best estimate approach was followed. Further, while reviewing the treatment history of medical illnesses, medication induced depression must be kept in mind, as many medications are known to cause depression (Table-3).Table 2: Some of the physical illnesses commonly associated with depressionTable 3: Medications known to cause depressionIt is always important to take the longitudinal life course perspective into account to evaluate for previous episodes and presence of symptoms of depression amounting to dysthymia. Evaluation of history also takes into consideration the relationship of onset of depression with change in season (seasonal affective disorder), peripartum period and phase of menstrual cycle. Further, the longitudinal course approach may also take into account response to previous treatment and whether the patient achieved full remission, partial remission and did not respond to treatment. An important aspect of diagnosis of depression is to rule out bipolar disorder. Many patients with bipolar disorder present to the clinicians during the depressive phase of illness and spontaneously do not report about previous hypomanic or manic episodes. Careful history from the patient and other sources (family members) often provide important clues for the bipolar disorder. It is often useful to use standardized scales like mood disorder questionnaire to rule out bipolarity. Treating a patient of bipolar depression as unipolar disorder can increase the risk of antidepressant induced switch. Presence of psychotic features, marked psychomotor retardation, reverse neurovegetative symptoms (excessive sleep and appetite), irritability of mood, anger, family history of bipolar disorder and early age of onset need to alert the clinicians to evaluate for the possibility of bipolar disorder, before concluding that they are dealing with unipolar depression. Area to be covered in assessment include symptom dimensions, symptom-severity, comorbid psychiatric and medical conditions, particularly comorbid substance abuse, the risk of harm to self or others, level of functioning and the socio-cultural milieu of the patient. In case patient has received treatment in the past, it is important to evaluate the information in the form of type of antidepressant used, dose of medication used, compliance with medication, reasons for poor compliance, reasons for discontinuation of medication, response to treatment, side effects experienced etc. If the medications were changed, then the reason for change is also to be evaluated. Wherever possible, unstructured assessments need to be supplemented by ratings on appropriate standardized rating scales. Depending on the need, investigations need to be carried out. The use of neuroimaging may be indicated in those with first-episode of depression seen in late or very late age; those have neurological signs, those having treatment resistant depression. Besides, patients, information about the illness need to be obtained from the caregivers too and their knowledge and understanding of the illness, their attitudes and beliefs regarding treatment, the impact of the illness on them and their personal and social resources need to be evaluated. FORMULATING A TREATMENT PLAN (FIGURE-1)Figure 1: Initial evaluation and management plan for DepressionFormulation of treatment plan involves deciding about treatment setting, medications and psychological treatments to be used. Patients and caregivers may be actively consulted while preparing the treatment plan. A practical, feasible and flexible treatment plan can be formulated to address the needs of the patients and caregivers. Further the treatment plan can be continuously re-evaluated and modified as required. EVALUATE THE SAFETY OF PATIENT AND OTHERS A careful assessment of the patient's risk for suicide should be done. During history inquiry for the presence of suicidal ideation and other associated factors like presence of psychotic symptoms, severe anxiety, panic attacks and alcohol or substance abuse which increases the risk of suicide need to be evaluated. It has been found that severity of depressive symptomatology is a strong predictor of suicidal ideation over time in elderly patients. Evaluation also includes history of past suicide attempts including the nature of those attempts. Patients also need to be asked about suicide in their family history. During the mental status examinations besides enquiring about the suicidal ideations, it is also important to enquire about the degree to which the patient intends to act on the suicidal ideation and the extent to which the patient has made plans or begun to prepare for suicide. The availability of means for suicide be inquired about and a judgment may be made concerning the lethality of those means. Patients who are found to possess suicidal or homicidal ideation, intention or plans require close monitoring. Measures such as hospitalization may be considered for those at significant risk. CHOICE OF TREATMENT SETTINGS Majority of the cases of depression seen in the clinical setting are of mild to moderate severity and can be managed at the outpatient setting. However, some patients have severe depression which may be further associated with psychotic symptoms, catatonic symptoms, poor physical health status, suicidal or homicidal behaviour etc. In such cases, careful evaluation is to be done to decide about the treatment setting and whenever necessary inpatient care may be offered. In general, the rule of thumb is that the patients may be treated in the setting that is most safe and effective. Severely ill patients who lack adequate social support outside of a hospital setting may be considered for admission to a hospital whenever feasible. The optimal treatment setting and the patient's ability to benefit from a different level of care may be re-evaluated on an ongoing basis throughout the course of treatment. Some of the common indications for inpatient care are shown in Table-4.Table 4: Some indications for inpatient care during acute episodesAll inpatients should have accompanying family caregivers. In case inpatient care facilities are not available, than the patient and/or family need to be informed about such a need and admission in nearest available inpatient facility can be facilitated. THERAPEUTIC ALLIANCE Irrespective of the treatment modalities selected for patients, it is important for the psychiatrist to establish a therapeutic alliance with the patient. 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. ENHANCED TREATMENT COMPLIANCE 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-5.Table 5: Measures which can improve medication complianceADDRESS EARLY SIGNS OF RELAPSE Many patients with depression experience patients as as their appropriate may be about the risk of can be to early and symptoms of episodes. Patients can also be asked to adequate treatment as early in the course of a as to the of a or TREATMENT for management of depression can be be into and psychosocial commonly used treatment or treatments used in patients with treatment resistant depression include and sleep treatment. In many cases are used as treatment, especially during the phase of treatment. in some cases, and may be used as an patient is not to of are available for management of depression and in all the have been shown to have in the management of depression. medication may be used as treatment for patients with or severe depressive The of antidepressant medications may be based on patient and as given in In general, of the side effect and are considered to be the include and the medication must be in the and the must be on the response and the side effects that the of and duration of Patients who have an antidepressant medication should be to the response to as as the of side effects and to the of include severity of illness, patient's with treatment, the availability of social support and the presence of comorbid medical may be kept to and address and to treatment with can be weeks of treatment. If at least a moderate is not in time and of the should be A may be considered as an treatment for patients with mild to moderate depressive disorder. features that may the use of a include the presence of significant psychosocial and for is an important factor that may be considered in the to use as the treatment to may also be an for as an treatment. which may be considered based on available and are shown in for and are the that have the best in the for management of depression. When is used as treatment, in to symptom it is with The psychiatrist should take into account factors the of for patients, including the type and of the necessary to and a therapeutic the of required to treatment and the necessary to and address The of outpatient during the acute phase from a in cases to as often as a of the type of the patient's response to treatment should be a given time and of may be by the to the patient to the family concerning depression and treatments can be to all patients. When can also be to family may be in some that depression is a illness and that treatments are necessary and available may be crucial for patients who their illness to a or regarding available treatment will help patients informed side effects and to important aspect of is the patient and especially family about the period of onset of of of are given in of of and is of patients who may require the combination of and In general, the that the of medication or used should be considered treatments for patients OF of depression can be into acute phase and phase of treatment is considered patient has depressive disorder. TREATMENT The of acute phase treatment is to remission, as presence of symptoms increase the risk of depression, poor quality of life and also recovery from physical illness. in in quality of life and The of acute phase treatment are shown in and the treatment is shown in and in the acute 2: of mild to moderate 3: of acute phase psychiatrist may between treatment including the combination of medication and or of an treatment is by clinical severity of and other factors patient medication may be used as treatment for patients with or severe major depressive disorder. features that may that medication are the treatment includes history of prior positive response to antidepressant medication, severity of symptoms, significant sleep and or of the need for Patients with severe depression with psychotic features will require use of combination of antidepressant and medication and/or The of an antidepressant medication is be based on the side the or of these side effects for patients, patient and comorbid physical and duration of an antidepressant medication has been it can be at and careful to be done to the response to as as the of side clinical conditions, and to the of include severity of illness, patient's cooperation and presence with treatment, and availability of social support of comorbid medical may be to and address and to treatment with can be weeks of treatment. If at least a moderate is not in time and of the maybe In the on the symptom severity and type of symptoms, such as presence of or anxiety, or other may be used for to If at least some is not of a of the treatment be and a change in antidepressant may be When patient during the weeks of antidepressant the dose must be to the If is than with weeks of dose and the medication compliance is a change in antidepressant may be If weeks of treatment, a moderate is not then a and of the diagnosis, and and treatment plan may be of the treatment may also include evaluation of patient adherence and the treatment plan can be by of therapeutic including the medication treatment, to antidepressant medication, antidepressant medications with other the treatment is the most the therapeutic patients are to be for an increase in the severity of side effects or of side to a different antidepressant medication is a common for patients, especially those who have not shown at least partial response to the medication is about and patients can be to an antidepressant medication from the (e.g., from an to or to from a different (e.g., from an to a Some expert suggests that while a with a different or of may be of antidepressant medications may be particularly for patients who have a partial response to antidepressant include a second antidepressant medication from a different or medication such as an etc. or increasing the of may be considered for patients who do not respond to medication treatment. any change in treatment, close need to be done. If at least a moderate level of in depressive symptoms is not seen an weeks of treatment, need to be done. may include the patient's diagnosis and and clinical factors that may be such as the presence of comorbid medical or psychiatric (e.g., alcohol or substance and and psychosocial that may be If information is to the patient's lack of adequate on the severity of depression, maybe of a of the used for management of depression, is level of evidence for use of The major of type of are patient and the availability of clinicians with appropriate and in clinical factors which will the type of include the severity of the depression. is for patients with depression who are life events, family poor social support and comorbid The optimal of may be based on type and of the the necessary to and a therapeutic the of required to treatment and the necessary to and address factors which also the of include the severity of illness, the patient's cooperation with treatment, the availability of social cost, and presence of comorbid medical the use of all patients and their caregivers may about the illness. of and in management of to role of like and other have been in of that to these need to be of these as is widely TREATMENT The of phase is to the achieved in the acute phase of treatment and of symptoms. The treatment to be is shown in Patients who have been treated with in the acute phase need to be on dose of these for weeks to period of from of are to support the use of in phase to The use of other somatic modalities may be useful in patients and/or have to in The of during the phase may be by patient's clinical as as the treatment If phase treatment is not indicated for patients who the patients may be considered for discontinuation of treatment. If treatment is careful be done for and treatment to be 4: for phase treatment of The of phase treatment is to recurrence of depressive episodes. an of patients with a of major depression have at least more episodes. phase treatment may be considered to The duration of treatment may be in the previous treatment history and of depressive episodes the has in the the treatment that was for acute and phase need to be used in the phase of to which the patient in previous phase is The of for and be reduced during the phase a is regarding the duration and to and not to treatment. is to extent that patients who have history of or more or need to be given 5: for phase of OF TREATMENT The to treatment may be based on the factors considered in the to treatment, including the of the and severity of past the persistence of depressive symptoms the presence of comorbid and patient When the is made to or in the the in which is done may be to the patient's When the is made to it is best to the medication over the course of at least weeks to may for the of symptoms or patients are treated and can be to full therapeutic In addition, such can help the of antidepressant medication discontinuation have been found to be more discontinuation of medications with and patients on may be given more and to have rates of discontinuation symptoms while and have The symptoms of discontinuation include symptoms, (e.g., and If the discontinuation is may be If mild to treatment or may be If it is antidepressant are to be and more the discontinuation of treatment, patients should be of the for a depressive may be informed about the early of depression, and a plan for treatment in the of recurrence of symptoms may be Patients may be for to If a patient a discontinuation of medication, treatments need to be In general, the previous treatment to which the patient in the acute and phase are to be OF TREATMENT Initial treatment with antidepressant medication to a response in of patients with depressive disorder. In some cases the lack of treatment response is a of diagnosis, treatment, or to and medical and psychiatric or other psychosocial treatment for at least weeks is necessary before concluding that a patient is not to a in care of a patient who has not to medication is out a and of the psychosocial and information at the diagnosis and any and including the medical alcohol or substance abuse or other psychiatric and psychosocial for at the diagnosis of treatment resistant depression is given in for at the diagnosis of clinicians require of medications of different for adequate duration before treatment resistant depression of involves of an of or other somatic treatments like for management of is given in for management of of an to an is the used as an other in use are and as to the of and It is reported that is useful in over of antidepressant and is The before full response to is to be in the range of If and may be for the duration of treatment of the acute in patients, may also increase the of antidepressant treatment. The dose for is of increased to in a use of Depression is a in case patient not respond to clinicians may use with close of side effects and of antidepressant a risk of and require dose of a in combination with has been reported to a particularly antidepressant However, to an increased blood level and of the the patient to the dose of the is involves use of a antidepressant and a a combination that is in severe depression, the risk of careful monitoring. to is good and the response rates are like any form of antidepressant treatment and it may be considered in all cases of moderate or severe major depression who do not respond to of medication resistant patients a response to may be before of as it has been reported to and recovery from a type of that occurs in a and has been as a to illness. evidence suggests that to the is a treatment for depression, not all patients a positive outcome. clinical report with it which such as duration and can the most is of the for OF often clinical situations which require special or can treatment of these situations is in of depression situations