Depression and Suicide _ ______________________________________________________________________
[114]. Behavioral activation is appealing to patients in that it is simple and easily taught, effective in reducing milder depression, and can be continued following the conclusion of therapy. Behavioral activation can also be used in difficult-to- treat populations, such as depressed dementia patients. Among the elderly, regular outings and get-togethers, participation in a senior day care program, or available nursing home activities can reduce depression [21; 115; 116]. Results of a 2010 meta- analysis suggest that among patients with mild or subclinical depression, antidepressants may be no better than placebo, and that behavioral activation plus lifestyle modifications alone may offer sufficient symptom reduction [117]. Physical Activity A robust body of evidence indicates that physical activity at a dose consistent with public health recommendations can lessen or alleviate symptoms of depression. Exercise therapy is very beneficial to patients with major depression, but the exercise must be continued over time to provide maximum benefit. Greater antidepressant effects occur when training continues beyond 16 weeks. Walking is a good initial option for many patients, and physically healthy adults should be encouraged to set a goal of 30 minutes of moderate-intensity aerobic exercise, three to five days per week [21]. DEVISING A TREATMENT PLAN The two primary treatment options for most patients with MDD are psychotherapy and pharmacotherapy [111]. Evidence-based guidelines recommend that the process of treatment selection involve shared decision making between provider, patient, and family members, and that the values, priorities, and goals of the patient be included in discussions of risks and benefits of treatment options [118]. Ongoing communication with other providers involved in the care of a patient is essential for coordination and monitoring and can involve different care providers in the same primary care clinic or the primary care provider and therapist or psychiatrist [22]. Combining pharmacotherapy and psychotherapy treatments should be considered for patients with MDD when practical, feasible, available, and affordable. Both approaches combined show better outcomes than either as monotherapy. When unable to combine therapy because of patient preference or problems with availability or affordability, consider psy- chotherapy when the presentation is mild-to-moderate, and antidepressants when depression is severe or chronic [21]. Patients with MDD with psychotic features should receive an antipsychotic and an antidepressant medication or electro- convulsive therapy (ECT). Lithium can be added in patients unresponsive to antipsychotic/antidepressant therapy [22]. Other specific factors should be considered in treatment planning, including the presence of substance abuse, specific features, and other comorbid disorders. If a patient displays signs of potential suicide, increasing the treatment intensity,
including hospitalization if needed, should be considered, and pharmacotherapy and psychotherapy should both be provided [22]. Alcohol or Substance Abuse/Dependence With active substance abuse, detoxify the patient before anti- depressant initiation when possible. Identifying patients who require antidepressants following the initiation of abstinence is difficult, because ongoing substance abuse can cause or amplify depressive symptoms that will dissipate with abstinence. Factors suggestive of benefit from early medication initiation include a family history of MDD, patient history of depression preceding alcohol or other substance abuse, or a history of significant depression during periods of abstinence. Use of some drugs of abuse, especially stimulants, may create a toxic interaction with monoamine oxidase inhibitors (MAOIs), and benzodiazepines and other sedative-hypnotics should be used with great caution, except as part of a detoxification regimen [22]. Specific Features As discussed, patients with MDD may present with features that specify the current episode as catatonic, melancholic, or atypical. Rapid alleviation of potentially life-threatening catatonia in patients with MDD with catatonic features may be necessary with intravenous lorazepam or amobarbital. ECT should be used immediately in unresponsive patients. Initiation of antidepressant medication should also begin, and catatonic patients given antipsychotic medication should be monitored for neuroleptic malignant syndrome [22]. Many treatment studies in symptom-based MDD subtypes (e.g., melancholic, atypical, anxious depression) have compared an active drug to placebo. Some report efficacy, but few have evaluated preferential subtype response [119; 120]. Comorbid Psychiatric Disorders Both depressive and anxiety symptoms respond to antidepres- sant medication treatment, although SSRIs and TCAs may initially worsen anxiety symptoms. Benzodiazepines may be needed as short-term adjunctive therapy but should not be used as monotherapy. Clomipramine and SSRIs are effica- cious in managing obsessive-compulsive symptoms, and all antidepressants should be initiated at a low starting dose [22]. Patients with MDD and comorbid personality disorders, especially borderline personality disorder, poorly respond to standard antidepressants, and MAOIs should not be used in patients with borderline personality disorder [22]. Psycho- dynamic psychotherapy may be beneficial in modifying the personality disorder in selected patients, although antisocial personality traits often interfere with treatment adherence and the psychotherapeutic relationship [22]. Other evidence suggests that comorbid personality disorders in patients with depression interfere with treatment response to interpersonal psychotherapy but not cognitive-behavioral therapy (CBT) [121].
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