Table 5.

Depression Management Guidelines

1. Education and discussion of the problem with patients and families.

2. Antidepressant medications in full doses usually with the selective serotonin reuptake inhibitors (SSRIs) and related drugs because they have fewer side effects, greater compliance, and greater likelihood of achieving full doses. Tricyclics can be used if the patient prefers. We believe that MAO inhibitors should be used only with treatment failures and under supervision of a psychiatrist.

3. Judge response at 5–8 weeks

a) Full responders (expected response), reassessed for complete remission in another 6 weeks, are placed on continuation treatment at the same dosage for 12 months. At that point, a reduction to one-half the dose be tried if the depression was mild or a first episode, especially in younger patients.

b) Nonresponders (little or no response) will be reassessed for accuracy of diagnosis and compliance; especially important are observing for unrecognized medical illness, interference from other medications, and covert substance abuse. Referral to psychiatry occurs if the patient is willing. Antidepressants can be increased in dose or changed, with continued close follow-up during the next 6 weeks, usually in consultation with the psychiatrist.

4. Counseling is urged, especially for patients who refuse or cannot take antidepressants. When that is refused, we urge consultation with a minister or other respected person. Other aspects of the treatment program also can be helpful in treating depression, e.g., exercise, relaxation, treatment of pain.

5. We also use smaller than therapeutic doses of a SSRI or other antidepressant for both sleep and pain management