5. Guideline: Acute Phase Management with Psychotherapy Objectives and Indications Evidence for Efficacy Cognitive Therapy Interpersonal Psychotherapy Brief Dynamic Psychotherapy Factors Affecting Response to Psychotherapy Selection of a Psychotherapy Frequency of Visits ... Depression and Other Nonpsychiatric Medical Disorders 9. Guideline: Continuation and Maintenance Treatment Options Objectives and Indications for Continuation Treatment Tables 1. Objectives and effects of different treatments 2. Strategic choices in the acute treatment of major depressive disorder 3. Considerations for acute phase medication 4. Number of randomized controlled trials of medication in patients with major depressive disorder . . 5. Meta-analyses of antidepressant medications for patients with major depressive disorder (intent-to-treat samples) 6. Meta-analyses of primary care antidepressant medication trials 7. Side-effect profiles of antidepressant medications 8. Pharmacology of antidepressant medications 9. Selecting among antidepressant medications for depressed outpatients 10. Objectives of acute phase psychotherapy 11. Number of randomized controlled psychotherapy trials in patients with major depressive disorder ... 12. Meta-analyses of psychotherapy trials in outpatients with major depressive disorder. 76 13. Considerations for combined treatment 90 91 15. Confounds in the diagnosis and treatment of depression in the elderly 101 16. Considerations for maintenance medication Figures 111 1. Guideline development process 2. Example of a meta-analysis result 3. Comparison of meta-analysis results for treatments A and B . . 4. Phases of treatment 5. Overview of treatment for depression 6. Steps in medication management of major depressive disorder 7. Six-week evaluation: responders to medication 8. Six-week evaluation: partial responders or nonresponders to medication 67 9. Relationship between major depressive and other current general medical disorders 105 10. Relationship between major depressive and other current psychiatric disorders. 107 Executive Summary Up to one in eight individuals may require treatment for depression during their lifetimes. The direct costs of treatment for major depressive disorder combined with the indirect costs from lost productivity are significant, accounting for approximately $16 billion per year in 1980 dollars. Despite the high prevalence of depressive symptoms and major depressive episodes in patients of all ages, depression is underdiagnosed and undertreated by primary care and other nonpsychiatric practitioners, who are, paradoxically, the providers most likely to see these patients initially. Depression may co-occur with other nonpsychiatric, general medical disorders or with other psychiatric disorders; it may also be brought on by the use of certain medications. Major risk factors for depression include a personal or family history of depressive disorder, prior suicide attempts, female gender, lack of social supports, stressful life events, and current substance abuse. The social stigma surrounding depression is substantial and often prevents the optimal use of current knowledge and treatments. The cost of the illness in pain, suffering, disability, and death is high. Once identified, depression can almost always be treated successfully with medication, psychotherapy, or a combination of both. Not all patients respond to the same therapy, but a patient who fails to respond to the first treatment attempted is highly likely to respond to a different treatment. The threshold for accepting a scientific report regarding treatment efficacy was the randomized controlled clinical trial, as this methodology is the most stringent test of treatment efficacy. Therefore, where studies are cited and data are available, conclusions are virtually certain. Once major depressive disorder is diagnosed, interventions that predictably decrease symptoms and morbidity earlier than would occur naturally in the course of the illness are logically tried first. The key initial objectives of treatment, in order of priority, are (1) to reduce and ultimately to remove all signs and symptoms of the depressive syndrome, (2) to restore occupational and psychosocial function to that of the asymptomatic state, and (3) to reduce the likelihood of relapse and recurrence. All treatments are administered in the context of clinical management, which is defined as education of and discussion with patients and, when appropriate, their families about the nature of depression, its course, and the relative costs and benefits of treatment options. Clinical management is to be distinguished from formal supportive therapy; the latter focuses on the management and resolution of current difficulties and life decisions using the patient's strengths and available resources. Supportive therapy is often combined with medication and clinical management in more severe, complex, or chronic cases. However, good clinical management is important with all depressed patients, whose pessimism, low motivation and energy, and sense of social isolation or guilt may lead them to give up, not to adhere to treatment, or even to drop out of treatment. Effective treatment rests on accurate diagnosis. The practitioner must first distinguish clinical depression, which is sufficiently severe and disabling to require intervention, from sadness or distress that is a normal part of the human experience. A formal mood syndrome should be treated. Treatments with established efficacy are preferred initially over less well tested or untested interventions. In selecting an appropriate treatment, the clinician weighs the certainty of treatment response against the likelihood and severity of potential adverse treatment effects. The optimal treatment is highly acceptable to patients, predictably effective, and associated with minimal adverse effects. It results in complete removal of symptoms and restoration of psychosocial and occupational functioning. Treatment proceeds in three phases: acute treatment, continuation treatment, and maintenance treatment. Acute treatment aims to remove all signs and symptoms of the current episode of depression and to restore psychosocial and occupational functioning (a remission). A remission (absence of symptoms) may occur either spontaneously or with treatment. If the patient improves significantly, but does not fully remit with treatment, a response is declared. If the symptoms return and are severe enough to meet syndromal criteria within 6 months following remission, a relapse (return of symptoms of the current episode) is declared. Continuation treatment is intended to prevent this relapse. Once the patient has been asymptomatic for at least 4 to 9 months following an episode, recovery from the episode is declared. At recovery, continuation treatment may be stopped. For those with recurrent depressions, however, a new episode (recurrence) may occur months or years later. Maintenance treatment is aimed at preventing a new episode of depression and may be prescribed for 1 year to a lifetime, depending on the likelihood of recurrences. Formal treatments for major depressive disorder fall into five broad domains: medication, psychotherapy, the combination of medication and psychotherapy, electroconvulsive therapy (ECT), and light therapy. Each domain has benefits and risks, which must be weighed carefully in selecting a treatment option for a given patient. Once selected, the initial treatment should be applied for a sufficient length of time to permit a reasonable assessment of the patient's response (or lack of response). If the treatment is going to be effective, a 4- to 6-week trial of medication or a 6- to 8-week trial of psychotherapy usually results in at least a partial symptomatic response; a 10- to 12-week trial usually results in a symptomatic remission, though full recovery of psychosocial function appears to take longer. The selection of the first and subsequent treatments should, whenever possible, be a collaborative decision between practitioner |