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  Important to have a structured plan   Combine medical with psychosocial STEP 4: Severe and complex depression; risk to life; severe self-neglect
Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and Medication, high-intensity psychological interventions, combined treatments, collaborative care and referral for further assessment and STEP 3: Persistent subthreshold depressive symptoms or mild to moderate
depression with inadequate response to initial interventions; moderate and Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions STEP 2: Persistent subthreshold depressive symptoms; mild to moderate
Assessment, support, psychoeducation, active monitoring and referral for STEP 1: All known and suspected presentations of depression
  ASK!   Have a high degree of suspicion in   Screen: Whooley questions, PHQ-9, Detection: Whooley Questions Recommended by NICE   During the past month, have you often been bothered   During the past month, have you often been bothered by having little interest or pleasure in doing things? If answer to either is “yes” then also ask:   Is this something you feel you need or want help with?   Lack of self confidence   Poor/increased appetite   Guilt/self blame   Agitation/slowed   Don’t forget longitudinal history   Routinely check for history of elevated mood. Patients often don’t volunteer this   US survey study (Hirschfeld RM, 2003) bipolar had diagnosis of unipolar depression   Subclinical/Subthreshold: significant   Moderate: 6 symptoms/moderate functional   Severe: Most symptoms present and marked   About depression, eg RCP leaflet,   About antidepressant: gradual onset   About psychological treatment.   Take account of patient preference Select Treatment From British Association Psychopharmacology and NICE   Antidepressants are first line treatment for moderate   Antidepressants are an option for short duration mild depression if history of moderate/severe recurrent depression or depression persisted >2-3 months   Antidepressants are not first line treatment for subthreshold depression but consider if history of moderate/severe recurrent depression or depression   Meta-analysis by Cipriani et al 2009 (Lancet) escitalopram, mirtazapine, venlafaxine (only   Match patient to medication based on   Consider toxicity in overdose   Patient preference   Generally will be SSRI first-line.   Be aware of drug interactions, citalopram is   CVS disease: Avoid TCA in those at high risk drugs which do not increase risk of cardiac events – SSRI esp sertraline, mirtazapine   Dementia: avoid TCA   Bleeding Disorders: remember SSRIs may   Pain reduces response to antidepressants.   Initially review patients (by phone or face-to-face) every 1-2 weeks as higher risk at start and change of treatment. Review may be shared between medical and   Response to treatment   Adherence   Side-effects   Suicide risk   Increase dose of antidepressant if needed. If   If not improving after 4-6 weeks on maximum tolerated dose then consider non-response strategy.   Early in treatment there is an increase   Early in treatment there is early   Likely to settle down   Lower dose and more cautious increase   For agitation or insomnia can use   Sidenafil for erectile dysfunction   Change antidepressant   Dietary advise and exercise for weight   High risk of relapse after depressive episode, esp in   So continue antidepressant at effective dose for 6   If there are risk factors(2+ episodes in recent past, residual symptoms, severe consequences to relapse, prolonged episodes) then continue for 2 years.   In high risk patients (> 5 episodes, comorbid conditions, very severe) consider long-term maintenance treatment.   Those with residual symptoms or high risk of relapse or who don’t wish to continue antidepressants should be   Reassess diagnosis   Assess adherence   Medication: Increase dose, change antidepressant,   Psychological treatment: add, increase intensity.   Other treatment: ECT   Outcome poor but improved by regular review/contact   Very little evidence to guide us on what next   STAR*D Study: sequenced treatment alternatives (4 levels). NIMH, 4041 participants, primary and secondary care. If SSRI fails then 25% of those who change to alternative antidepressant will recover regardless of antidepressant chosen. Diminishing   Change to another SSRI or alternative new generation   If require third change, use antidepressant from   Caution when switching antidepressant from fluoxetine to others, as fluoxetine has v long half-life   Fluoxetine and paroxetine inhibit metabolism of TCA   Acute treatment of severe depression which   Risks: GA, cognitive impairment   Antidepressant required to prevent relapse.   Tiny proportion have maintenance ECT as   Discontinuation syndrome, if severe

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