nonanxious psychiatric conditions, and they can enhance a careful clinical formulation rendered by a clinician well trained in the diagnosis of depressive disorders. Where the differential diagnosis is in doubt, psychological tests may help to tip the balance in favor of one or the other condition. Like laboratory tests, however, psychological tests should not be used for routine screening purposes or administered for all differential diagnostic situations.

Ongoing Clinical Reassessment

Guideline: A critical element in the differential diagnosis of depressive disorders is ongoing clinical reassessment. (Strength of Evidence = B.)

Most patients with major depressive disorder respond partially to medication within 2 to 3 weeks, and full symptom remission is typically seen in 6 to 8 weeks. Most patients receiving time-limited psychotherapy respond partially by 5 to 6 weeks and fully by 10 to 12 weeks. Patients who fail to show this pattern can be detected through careful interviewing or by clinical or self-report rating scales. In these patients, a reevaluation is indicated. The clinical reevaluations may include repeating a thorough general medical and psychiatric history, physical examination, and a more thorough medical laboratory evaluation. For patients on selected medications, blood level measurements may help gauge whether the serum level of antidepressant is in the therapeutic range.

A significant subset of patients with major depression also exhibit maladaptive personality traits or disorders. When the underlying mood disorder is successfully treated, the expression of these maladaptive traits may partially or completely resolve (Joffe and Regan, 1988; Thompson, Gallagher, and Czirr, 1988). However, studies suggest that patients with such preexisting personality disorders are less likely to exhibit a full therapeutic response in affective symptoms to either medication or timelimited psychotherapy, or they may take longer to respond fully. In those who respond only partially to treatment and in whom personality disorders are suspected, psychological testing may be useful to determine the presence of personality disorders. If present, the case for combined treatment with medication and psychotherapy may be stronger.

These are general principles whose application to individuals requires judgment, logic, and flexibility. First, it is necessary to define a response, which is usually thought to be at least a 50 percent improvement in baseline (pretreatment) symptom severity or a global judgment that the patient is at least much improved. A remission is defined as either the presence of few or no symptoms or a global patient report of marked improvement. In some cases, other ongoing problems, such as chronic severe life stresses, may slow the response or impair the likelihood of attaining a fully asymptomatic state in 10 to 12 weeks. In such patients, longer observation periods may be needed while treatment continues.

Finally, improvement in some symptoms (e.g., insomnia) may not be the best way to judge overall treatment effectiveness. For example, the side effects of medication (e.g., sedation) or psychotherapy (e.g., improved sense of hope or optimism) may result in abatement of selected symptoms while failing to remove all symptoms of the depressive disorder.

The timing and type of reassessment, and the interpretation of the results of this reassessment are important. Based on panel consensus and an awareness that most psychopharmacology studies have used assessments conducted every 1 to 2 weeks to evaluate response in efficacy trials, it is recommended that medication treatment visits or telephone contacts initially be weekly to ensure adherence, adjust dosage, and detect and manage side effects. After 3 to 4 weeks, visits may be less frequent for most patients. The degree of response/remission can be assessed at each visit, as well as any evidence of side effects. Whether the clinical interview is supplemented with a symptom-rating scale or not, the practitioner should inventory all of the criterion symptoms of depression included in the patient's initial complaint. For those with personality disorders or severe ongoing life stresses, as long as the patient is showing some significant improvement over baseline, the treatment need not be changed for 8 to 10 weeks. For others, an earlier judgment can be made to change the treatment if no meaningful response is found (or to change earlier, if adverse side effects are encountered).

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