| Paper authors: | Shiv Gautam, Akhilesh Jain, Manaswi Gautam, Vihang Vahia, Sandeep Grover |
| Year of paper publication: | 2017 |
| Post authors: | Alice Erchov, Lisa Ridgway, Fidel Vila-Rodriguez |
| Download the research article: | Gautam et al. (2017) Clinical Practice Guidelines for the management of Depression |
Introduction
Depression is known to cause difficulty in daily functioning, self-esteem, sleep, and emotions. With all the research we’ve done with depression, guidelines are needed to organize this information into comprehensible and universal standards of care, informed by our most up-to-date understanding of diagnosis and treatment. The guideline in question comes from India in 2017 and is a keystone because it was the first to officially recommend the use of neuromodulatory treatments (specifically, electroconvulsive therapy; ECT) in severe cases of depression.
Assessment, Evaluation, and Diagnosis of Depression
- This guideline proposes that the diagnosis of depression requires the presence of several symptoms, such as…
- Depressed mood
- Loss of interest/pleasure
- Low energy, fatigue
- Reduced concentration and attention
- Reduced self-esteem and confidence
- Feelings of guilt and worthlessness
- Bleak and pessimistic views of the future
- Ideas or acts of self-harm or suicide
- Disturbed sleep
- Diminished appetite
- Also,
- Symptoms must be present for at least 2 weeks
- Individual must experience psychosocial dysfunction (i.e., difficulties in daily life)
- Any other medical condition or medication that could be causing the same symptoms should be ruled out (e.g., blood tests, physical exams, family history, etc.)
- Physicians should also consider the severity of symptoms and extent of impact on daily life
First-Line Treatments
- This guideline states that those who have mild-moderate depression are usually recommended medication, therapy, or – the most effective option – both!
- All antidepressants have been shown to have similar success, but there are some more commonly used than others
- For example, Selective Serotonin Re-uptake Inhibitors (SSRIs) like escitalopram, sertraline, fluoxetine, etc.
- Usually, improvement takes ~4-6 weeks
- For people with severe depression, individuals may consider using electroconvulsive therapy (ECT) in addition to antidepressants
- i.e., those with psychotic symptoms or suicidal thoughts/behaviours
The Goals of Treatment Change Over Time
- In the first “acute” phase of treatment, the goal is to achieve remission (i.e., a “cure”), such that symptoms are no longer present or no longer disrupt an individual’s ability to function
- If symptoms improve, a patient may move onto the “continuation” phase, where the goal is to maintain the gains achieved in the acute phase and prevent relapse
- Then, if gains remain consistent, individuals may enter the “maintenance” phase, where the goal is primarily to prevent relapse, which can occur in between 50-85% of cases
What Happens When Treatment Doesn’t Work?
- A major complication for treatment is whether patients are able or willing to stick to a strictly prescribed medication regiment (i.e., adhere to the treatment schedule)
- To improve the likelihood that patients will adhere to treatment, physicians can work on building a therapeutic alliance (a good relationship) and to provide the proper information and knowledge needed to follow a regimen
- If treatment is only partially effective, clinicians can consider changing medication doses or regimens
- If treatment doesn’t work, clinicians can consider changing medications or therapy approaches entirely
- E.g., change from SSRIs to another class of medication
- If treatment still doesn’t work (20-30% of cases), an individual may be considered to have treatment-resistant depression
Treatment Resistant Depression
- Individuals with treatment-resistant depression are often given the option of more intense or experimental options
- For instance, at this stage clinicians may start combining antidepressants with other types of medications, or prescribing more than one at once
- The guidelines also suggest the use of neuromodulatory treatment regardless of severity: either ECT or repetitive transcranial magnetic stimulation (rTMS)
Conclusion
Depression is complex, and clinicians rely on research to be able to know what the best approach of diagnosis or medication is for any individual. The 2017 guidelines reviewed here are a keystone: they were the first to recommend the use of ECT as a first-line treatment (for severe depression).