Evaluation and Screening and Treatment for Depression

Evaluation of Depression

How should depression be evaluated?

√: The clinical interview is the essential procedure for the diagnosis of depression. The International Classification of Diseases (ICD) and Diagnostic and Statistical Manual of Mental Disorders (DSM) provide a set of agreed criteria to rely on.

C: Due to the existence of different factors that may affect the progress, course and severity of depression, it is recommended to evaluate the following areas:

• Features of the episode: duration, number and intensity of symptoms, comorbidity


• Psychosocial assessment (social support and interpersonal relationships)


• Degree of associated dysfunction and/or disabilities


• Risk of suicide


• Response to previous treatment

C: It is recommended to assess the risk of suicide in patients with depression, considering the following factors:

• Presence of previous suicide attempts, other comorbid mental disorders and substance abuse


• Specific symptoms such as hopelessness, anxiety, agitation or suicidal ideation


• Other risk factors such as physical illness, chronicity, pain or disability, family history of suicide, social factors and a history of suicide in the environment

Q: When assessing depression, it is recommended to consider the heterogeneity of its presentation as well as the perception patients have about their symptoms and the disorder.

Q: It is recommended to pay special attention to issues that affect the daily lives of patients with depression which may have a greater functional impact.

Q: The assessment should consider the sociodemographic and cultural factors that may affect the development or maintenance of depressive symptoms and influence treatment, such as sex, family, social network and perceived stigma.

Q: The meaning and impact of depression on the patient's family and any needs that may arise should be explored; especially regarding children, adolescents and family dependent upon the depressed patient.

Q: It is recommended to encourage the communication of feelings and emotions in an empathetic and respectful environment.

Q: When a diagnosis of depression is made, all the necessary information about the disorder and treatment options, as well as explanations to reduce the guilt and stigma attached, must be promoted and provided.

Assessment Instruments

Which scales have the best psychometric properties for the assessment of depression in adults?

√: The scales provide additional information in the evaluation, but cannot replace the clinical interview.

D: Some of the scales that may be useful in assessing depression are the Hamilton Rating Scale for Depression (HRSD), the Montgomery Asberg Depression Rating Scale (MADRS), the 9-item (Brief) Patient Health Questionnaire (PHQ-9) and the Beck Depression Inventory (BDI).

Depression Screening

Does screening improve health outcomes in depression?

B: Routine screening for depression is not recommended for the general population, as there are reasonable doubts about its effectiveness.

B: Clinicians should be alert to the possibility of depression, especially in patients with risk factors who also have symptoms such as insomnia, low mood, anhedonia and suicidal ideation.

B: In primary care, when an indicator for depression is observed in a routine examination, it is recommended to use two questions about mood and the ability to enjoy to assess for the presence of depressive disorders. If the response is positive, an appropriate psychopathological assessment is recommended.

Treatment

Depression Care Models and General Management Principles

How effective are stepped-care and collaborative models?

Care Models

B: The management of depression in adults should be performed as a stepped care and collaboration model between primary care and mental health, so that interventions and treatments are tailored to the status and evolution of the patient.

General Treatment Recommendations

√: The treatment of depression in adults should be comprehensive and cover all psychotherapeutic, psychosocial and pharmacological interventions which may improve well-being and functional capacity.

√: The management of depression should include psychoeducation, individual and family support, coordination with other professionals, care of comorbidity and regular monitoring of mental and physical status.

√: The initial selection of the mode and scope of treatment should be based on clinical findings and other factors, such as previous history, the availability of treatment, patient preference and the ability to provide support and containment in the environment.

D^CPG: A structured patient monitoring plan should be established. The assessment and monitoring frequency of symptoms should be according to severity, comorbidity, cooperation with treatment, social support and the frequency and severity of side effects of the prescribed treatment.

Q: With the consent of the patients, both they and their relatives should take an active role in making decisions about the treatment and care plan development.

Q: Patients and their relatives should be offered support to develop coping strategies, and should be informed of the existence of patient associations and resources which can be of help.

D^CPG: Verbal information should be backed up with written documents whenever possible.

Psychotherapeutic Treatment

How effective are different psychological interventions in patients with depression?

√: The availability of psychotherapeutic treatment should be ensured for patients who need it.

B: In mild-moderate depression, a brief psychological treatment (such as cognitive behavioural therapy or problem-solving therapy) of 6 to 8 sessions over 10 to 12 weeks should be considered.

B: The psychological treatment of choice for moderate to severe depression is cognitive behavioural therapy or interpersonal therapy, of 16 to 20 sessions over 5 months.

B: Cognitive behavioural therapy should be considered for patients with inadequate response to other interventions or a prior history of relapses and/or residual symptoms.

C: Other psychological interventions should be considered when addressing comorbidity or the complexity of family or marital relationships, often associated with depression.

B: Patients with chronic and/or recurrent depression are recommended a combination of drug therapy and cognitive behavioural therapy.

Pharmacotherapy

How long and at what dose should drug treatment be maintained after remission of depressive symptoms?

√: Before starting antidepressant treatment, patients must be adequately informed of the expected benefits, side effects and possible delay in the therapeutic effect.

A: The initial selection of drug therapy should be based mainly on the side effect profile and tolerability, safety and pharmacological properties, as well as other factors such as previous response to treatment, cost and patient preferences.

A: Selective serotonin reuptake inhibitors (SSRIs) are antidepressants with the most evidence and better risk/benefit ratio, and should be considered as the first choice of treatment.

√: All patients with moderate depression treated with drugs should be re-assessed within 15 days of the treatment start, and within 8 days in the case of severe depression.

D^CPG: Benzodiazepine treatment may be considered for patients with anxiety, insomnia and/or agitation, although they should not be used for longer than 2 to 3 weeks to prevent the development of dependence.

√: Patients undergoing drug therapy must be closely monitored, at least for the first 4 weeks.

D: Antidepressant treatment should be maintained for at least 6 months after remission of the episode, and aspects such as previous episodes, comorbidity and the presence of other risk factors should be evaluated before deciding on withdrawal of treatment.

A: It is recommended that maintenance treatment be performed with the same dose at which the response was achieved.

D^CPG: To avoid withdrawal symptoms, the antidepressant treatment dose should be reduced gradually, usually over a period of 4 weeks; particularly for drugs with short half-lives like paroxetine or venlafaxine.

D^CPG: If withdrawal symptoms occur, a diagnostic confirmation should be performed and, if the symptoms are significant, reintroducing the original antidepressant at effective doses should be considered (or the use of another antidepressant in the same class with a long half-life) and the dose gradually reduced.

Q: When drug treatment is prescribed, the patient's perception should be explored and a positive attitude will be favoured. In addition, adequate monitoring for side effects, as well as evolution of the symptoms and functional capacity, should be performed. Moreover, after obtaining patient authorisation, any doubts the family has about the treatment must be clarified to gain their support.

Strategies for Resistant Depression

Psychotherapeutic Strategies in Resistant Depression

What is the role of psychotherapy as an enhancement or alternative in patients with resistant depression?

B: A combined therapy of cognitive behavioural therapy and antidepressant pharmacotherapy is recommended for patients with resistant depression.

Pharmacological Strategies in Resistant Depression

What pharmacological strategies are most effective in patients with treatment-resistant depression?

√: The following is recommended for patients who do not improve with initial antidepressant treatment for depression:

• Review of diagnosis


• Verify compliance with taking the appropriate dosage and treatment time


• Assess the existence of disease awareness, motivation to change and possible comorbidity

√: The following is recommended for patients with a partial response after the 3rd or 4th week:

• Wait for clinical evolution until the 8th week


• Increase the drug dose to the maximum therapeutic dose

B: If the patient does not respond by the 3rd or 4th week of treatment, any of the following strategies could be attempted:

• Change of antidepressant to another in the same or a different family


• Combination of antidepressants


• Enhancement with lithium or antipsychotics

C: When the strategy is changing the antidepressant, a different SSRI or another second-generation antidepressant should initially be evaluated. If there is no response, an antidepressant with greater side effects, such as a tricyclic or monoamine oxidase inhibitor (MAOI), could be assessed.

C: The combination of SSRI and mianserin or mirtazapine may be a recommendable option, bearing in mind the possibility of adverse effects.

C: Enhancement with lithium or antipsychotics, such as olanzapine, quetiapine, aripiprazole or risperidone may also be a strategy to consider, bearing in mind the possibility of greater adverse effects.

D^CPG: When enhancement or a drug combination is used:

• Be aware that these strategies usually increase adverse effects


• Select those drugs for which there is information on safety in combined use


• Document the rationale for the strategy


• Monitor carefully for adverse effects

√: There are insufficient data to recommend enhancement with carbamazepine, lamotrigine, topiramate, valproate, pindolol, thyroid hormones, zinc or benzodiazepines.

Electroconvulsive Therapy

What is the safety and efficacy of electroconvulsive therapy as a treatment for depression?

A: Electroconvulsive therapy should be considered a therapeutic option in patients with severe depression; mainly if there is a need for a rapid response due to high suicidal intent, severe physical damage or when other treatments have failed.

√: ECT should always be given by experienced professionals, following a physical and psychiatric assessment and in a hospital setting; and informed consent is essential.

Q: The decision to use ECT should be made jointly with the patient and/or family, by taking into account factors such as diagnosis, type and severity of symptoms, medical history, risk/benefit ratio, alternative therapies and patient preference.

Q: Should ECT be required, it is recommended to place special emphasis on providing all the necessary information, focusing on the purpose of the procedure, the side effects and a treatment plan.

Vagus Nerve Stimulation as Adjunctive Treatment for Resistant Depression

What is the safety and efficacy of vagus nerve stimulation as adjunctive treatment for resistant depression?

√: The use of vagus nerve stimulation outside the scope of research is discouraged due to the invasive nature of the procedure, uncertainty about its efficacy and adverse effects.

Transcranial Magnetic Stimulation as Adjunctive Treatment for Resistant Depression

What is the safety and efficacy of transcranial magnetic stimulation as adjunctive treatment for resistant depression?

B: Transcranial magnetic stimulation is not currently recommended as a treatment for depression, due to uncertainty about its clinical efficacy.

Other Treatments

Exercise

Is physical exercise effective in patients with depression?

B: Patients with depression are strongly encouraged to perform physical exercise as a healthy living habit. It is imperative that the patient is motivated and willing to do exercise, according to their physical condition and tailored to their individual preferences.

B: Physical activity should be considered an adjunct to antidepressants and/or psychotherapy in severe and moderate depression.

St. John's Wort

What is the safety and efficacy of St. John's wort in the treatment of adult depression?

B: Although there is evidence of the efficacy of St. John's wort in the treatment of mild to moderate depression, its use is not recommended for the following reasons:

• Ignorance of the active ingredients, mechanisms of action and persistence of the antidepressant effect


• A lack of standardisation of the dose


• The variability of different commercial preparations, which may have different amounts and proportions of its components and may not be therapeutically equivalent

B: Healthcare professionals should inform patients taking St. John's wort of its serious potential interactions with some drugs, some of which are commonly used, such as oral contraceptives.