When do you screen for depression, and what tools do you use?  • Consider screening patients with risk factors for depression, or be alert to the possibility of depression in high-risk patients, following up when clinical symptoms are noted (Joffres et al., 2013; Lam et al., 2016)  • A positive response on an initial 2-question screen (“During the last month, have you often been bothered by feeling down, depressed or hopeless? During the last month, have you often been bothered by having little interest or pleasure in doing things?”) can be followed up using the PHQ-9 (Kroenke and Spitzer, 2002)

How do you determine treatment goals for an individual patient?  • An individual patient’s treatment goals focus on full and sustained functional recovery across all aspects of MDD (McIntyre et al., 2015). The goal should include symptomatic remission, but also functional recovery, including societal, interpersonal, work, and family domains, and any other health outcomes defined by the individual patient and/or clinician (Zimmerman et al., 2006; McIntyre et al., 2015).  • The patient’s concept of remission may differ from that of the treating physician (Zimmerman et al., 2006).

What factors do you consider in selecting an antidepressant?  • The individual patient’s diagnostic specifiers, symptoms and severity, areas of impairment, other clinical characteristics, and medical history together with patient biases and preferences for treatment should be considered when choosing an antidepressant (National Institute of Mental Health, 2015; Habert et al., 2016; Kennedy et al., 2016).  • A range of factors (age, gender, MDD severity, predominant symptoms, diagnostic subtype, and comorbidities) could be associated with differences in efficacy or tolerability for specific drugs or classes (Uher et al., 2012; Kennedy et al., 2016).

What baseline assessments (for symptoms and function) do you use? How do you assess progress during treatment? What scales do you use?  • The PHQ-9 and SDS are brief, validated scales that can be used to measure baseline symptoms of depression and functional impairment, respectively (Kroenke and Spitzer, 2002).  • The same instruments can be administered weekly during acute treatment to assess changes in symptoms and function during treatment.  • Patients can also monitor changes in symptoms and share results and concerns with their clinician via mobile device applications (Mood Disorders Society of Canada 2014; Mohr et al., 2015).

How early do you optimize the treatment step when needed?  • Early improvements in depressive symptoms and in functioning, measured 1 to 4 weeks after initiation of treatment, predict later remission or recovery (Koran et al., 1995; Szegedi et al., 2003; Henkel et al., 2009; Kok et al., 2009; Szegedi et al., 2009; Lin et al., 2011; Joel et al., 2014; Lam et al., 2014; Soares et al., 2014a)  • Information from the first week or 2 of treatment can be useful for making dose adjustments (Kennedy et al., 2016); a switch to another antidepressant or addition of adjunctive treatment should be considered after 2 to 4 weeks if no improvement is noted with a dose adjustment or if the patient does not tolerate the dose increase (Kennedy et al., 2016).

What are the major obstacles to adherence? How do you monitor for adherence?  • Obstacles to adherence include poor tolerability, social stigma, inadequate patient education, lack of patient motivation, concerns about medication cost, weight gain, sexual dysfunction, delayed onset of efficacy, failure of patients to perceive benefits of treatment, and premature discontinuation of treatment after symptoms have improved (Masand, 2003; Ashton et al., 2005; Burra et al., 2007; Fortney et al., 2011)  • Tools for monitoring adherence to antidepressant medication include electronic monitoring, pill counts, medication diaries, patient self-reporting, chart reviews, prescription renewal, and pharmacy records (Osterberg and Blaschke, 2005; Velligan et al., 2006; Byerly et al., 2007; Nakonezny et al., 2008; Faurholt-Jepsen et al., 2014; Sutton et al., 2014; Orrell et al., 2015).

How do comorbid conditions (psychiatric or general medical) affect a long-term treatment plan?  • Because the presence of comorbid psychopathologies is a risk factor for recurrence of depression, long-term treatment is recommended for patients with comorbid conditions (Lam et al., 2016).  • Treatment efficacy for both antidepressant and psychological treatments may vary with medical of psychiatric comorbidities, so these should be taken into account when developing a long-term treatment plan (Kennedy et al., 2016; Parikh et al., 2016).  • The long-term treatment plan should also include addressing comorbid conditions in the maintenance period (Lam et al., 2016).

Abbreviations: MDD, major depressive disorder; PHQ-9, 9-item Patient Health Questionnaire; SDS, Sheehan Disability Scale.