Depression treatment guidelines

Calabrese JR, Kasper S, Johnson G, et al. International consensus group on bipolar I depression treatment guidelines. J Clin Psychiatry 2004 65(4) 569-579. 

Treatment of depressive episodes in bipolar disorder patients presents a particular challenge because of the risk of a pharmacologic mood switch to mania, although there is not complete agreement about such risk. Treatment guidelines suggest lithium or lamotrigine as first-line therapy.17,41 Olanzapine has also demonstrated efficacy in treatment of bipolar depression, and quetiapine is under review for approval of treatment of bipolar depression.42 When these fail, efficacy data support use of antidepressants. 

These two patient types were chosen to represent different levels of illness severity. Clinical treatment guidelines recommend quite clearly that the first type of patient presenting with moderate major depression symptoms receive treatment (psychotherapy, antidepressant drugs, or some combination), but for the second type of patient presenting with less severe symptoms the appropriate treatment is equivocal and ambiguous. ... 

Some patients with bipolar disorder will need antidepressants. Although the switch rate into mania or induction of rapid cychng by antidepressants is controversial, these agents do appear to present a risk for some patients, often with devastating consequences. Therefore, when a patient with bipolar disorder is prescribed an antidepressant, it should only be in combination with a medication that has established antimanic properties. Controlled comparative data on the use of specific antidepressant drugs in the treatment of bipolar depression are sparse. Current treatment guidelines extrapolate from these few studies and rely heavily on anecdotal chnical experience. Overah, tricyclic antidepressants should be avoided when other viable treatment options exist. Electroconvulsive therapy should be considered in severe cases. 

On the basis of these findings, treatment guidelines have recently evolved so that depression is not just treated until a response is seen but treatment is continued after attaining a response, so that relapses are prevented (Tables 5—15 and 5—16). Those with their first episode of depression may need treatment for only 1 year following response, unless they had a very prolonged or severe episode, were elderly, were psychotic, or had a response but not a remission. Those with more than one episode may require lifelong treatment with an antidepressant, as the risk of relapse skyrockets the more episodes that a patient experiences (Tables 5 — 15 and 5 — 16). Antidepressant treatment reduces these relapse rates, especially in the first year after successful treatment (Figs. 5 — 11 and 5 — 12). 

Treatment guidelines for depression and anxiety increasingly emphasize the value of longer-term maintenance treatment with antidepressants in order to prevent recurrence of illness. It is therefore important to assess the adverse effects burden of longer-term medication. The change in adverse effects profile over 1 year of treatment has been studied in a double-blind, placebo-controlled study of maintenance treatment with imipramine (average daily dose 160 mg) in 53 patients with panic disorder (15). Adverse effects of imipramine, such as sweating, dry mouth, and increased heart rate, persisted over the year... 

Treatment Guidelines for Schizophrenia, Major Depression, Bipolar Illness, Panic Disorder, Generalized Anxiety Disorder, Obsessive Compulsive Disorder and Social Anxiety Disorder, American Pharmaceutical Association Publications Bethesda, Maryland, copyright 1998-2000. 

The popularity of these drugs, especially the newer-generation antidepressants, has risen dramatically. It is questionable, however, why the trend to medicate all depressive symptoms continues to rise, especially after current medical treatment guidelines have recommended that depression associated with reactive or external environmental pressures do not call for drug therapy. Perhaps what complicates matters for practitioners is that some clients present symptoms reflective of both endogenous and... 

Based on these treatment guidelines, however, drug therapy is recommended for individuals with a first-generation family history of major depression or a history of previous or recurrent episodes. 

Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry 2000 157(4 suppl) lM5. 

Perhaps the best indication of the difficulties that are posed by selective publication is provided by the problems that NICE faced when drawing up its 2004 guidelines for the treatment of depression. Having read our meta-analysis of the FDA data, NICE contacted me in the hope of adding the unpublished data to their... 

Bauer M et al. (2002). World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders. Part 1 Acute and continuation treatment of major depressive disorder. World Journal of Biological Psychiatry, 3, 5-43. 

Data from Torrey EF, Knable MB. Surviving Manic Depression A Manual on Bipolar Disorder for Patients, Families and Providers. New York Basic Book, 2002 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed.. Text Revision. Washington, DC American Psychiatric Association, 2000 382-401 and American Psychiatric Association, Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry2002 159 1-50. 

The TCAs are the only antidepressant class in which effectiveness is dependent on serum level. Attainment of the minimal therapeutic level is typically required for effectiveness. Exceeding the maximum treatment level usually provides no additional benefit and risks toxicity. Unique in this regard is nortriptyline, which is the only TCA with a therapeutic window. This means that beyond the maximum therapeutic level of 150ng/mL nortriptyline not only risks toxicity but is actually less effective at treating depression. Please refer to Table 3.9 for a summary of dosing guidelines and therapeutic levels. 

American Psychiatric Association. 2003. Practice Guidelines for the Treatment of Patients with Major Depression. Available at www.psych.org/psych pract/treatg/pg/ Depression2e.book.cfm. Last accessed luly 18, 2004. 

Depression Guideline Panel. 1993. Depression in Primary Care Treatment of Major Depression. Rockville, MD U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. 

Donohue, Julie M., Ernst R. Berndt, Meredith Rosenthal, ArnoldM. Epstein, and Richard G. Frank. 2004. Effects of Pharmaceutical Promotion on Adherence to Guideline Treatment of Depression. Medical Care 42(2) 1176-1185. 

A series of studies demonstrates a synergistic effect between drug therapies and psychodynamic talk therapies. The effectiveness of each form of therapy used independently is less than their combined use in the case of major depression. See A. Solomon, The Noonday Demon An Atlas of Depression (New York Scribner s, 2001) E. Good, Chronic Depression Study Backs the Pairing of Therapy and Drugs, New York Times (May 18, 2000) L. Altshuler et al., Treatment of Depression in Women A Summary of the Expert Consensus Guidelines, of Psychiatric Practice 7 (May 2001) 185-208. Kleinman, Rethinking Psychiatry p. ii. 

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