Depression and Suicide _ ______________________________________________________________________
Older Age The same factors used in therapy selection with younger patients also apply to the elderly, although treatment response may take longer to achieve [22]. The starting dose of phar- macotherapy and rate of dose escalation should be carefully considered, as the elderly are more susceptible to medication side effects, especially hypotension and anticholinergic effects [22]. Weight loss may be a concern for some older patients, who may benefit from medication that promotes weight gain [21]. The collaborative care approach with the elderly involves a treatment team composed of a depression care manager, pri- mary care physician, and psychiatrist who provide a tailored approach to meet individual patient’s needs and preferences. This approach is based on education, behavioral activation, antidepressants, brief problem-solving therapy, and relapse prevention [127]. Collaborative care has demonstrated consid- erably greater and more sustained improvement of depressive symptoms in the elderly than usual care [128]. Family History A family history of bipolar disorder or acute psychosis indicates the need to monitor the patient for signs of bipolar disorder and treatment-emergent mania. A family history of recurrent MDD increases the likelihood of recurrent episodes and under- scores the importance of maintaining treatment response. A family member with positive treatment response to a specific antidepressant offers important information to guide antide- pressant selection [22]. Comorbid Medical Conditions As with psychiatric conditions, comorbid medical conditions can impact the treatment plan for patients with depression. Pharmacologic agents should be chosen carefully in these patients due to the increased risk for adverse events and drug-drug interactions, and the following considerations are suggested [22]: • Hypertension or cardiac conditions: Monitor vital signs and cardiac rhythm when treating with TCAs, SNRIs, or antidepressants with anticholinergic effects. • Seizure disorders: Use with caution antidepressants that lower the seizure threshold, such as bupropion, clomipramine, and maprotiline. • Parkinson disease: Serotonergic agents may worsen symptoms, and bupropion may benefit the illness but worsen psychosis if present. Selegiline may interact with L-DOPA, an agent used in the treatment of Parkinson disease. • Obesity: Monitor for weight gain with most antidepres- sants. • Sleep apnea: Choose an antidepressant with little daytime sedation.
• HIV infection: Carefully consider the potential drug- drug interactions between psychotropics and antiretro- virals. • Chronic pain: SNRIs and TCAs are preferred over SSRIs and MAOIs. OPTIONS FOR INITIAL THERAPY In mild-to-moderate depression, psychotherapy can be equally as effective as medication, although with severe depression, antidepressant medication is usually necessary [129; 130]. Psychotherapy can significantly reduce symptoms, restore psy- chosocial and occupational functioning, and prevent relapse in patients with major depression [131]. It is especially useful in addressing the psychosocial stressors and psychologic factors that impact the development or maintenance of depressive symptoms [22]. Support and education in the primary care setting are critical to improving patient adherence and follow- through with treatment. Patient factors such as the nature and duration of depressive symptoms, beliefs and attitudes toward psychotherapy, and early-life experiences (e.g., history of trauma) contribute to psychotherapy treatment response [22; 132]. Patient expectations as to the outcome of therapy, par- ticularly the expectation that treatment will lead to an improve- ment in symptoms, is linked to favorable therapeutic outcomes [133]. Because antidepressants and psychotherapy are both effective, careful consideration of patient preference for mode of treatment is appropriate, and a referral for psychotherapy should be given whenever psychologic or psychosocial issues are prominent or if the patient requests it [134; 135; 136]. Phases of Treatment With the traditional three-phase model of acute, continuation, and maintenance, the distinction between continuation and maintenance phases was based on a theoretical difference between relapse (symptom recurrence before resolution of current episode) and recurrence (symptoms that constitute a new episode, after recovery from previous episode) [137; 138]. However, studies have highlighted the lack of evidence to sup- port distinct demarcations between relapse and recurrence episodes, and a two-phase model (acute and maintenance) is now recommended [62; 139]. Acute Phase The primary goals for the initial 8- to 24-week acute treatment phase are symptom remission, meaning that signs and symp- toms of depression are absent or nearly so, and restoration of psychosocial functioning. Full symptom remission is important because residual depressive symptoms are risk factors for relapse and negative predictors of long-term outcomes. Clinicians can help patients achieve these goals through establishing a therapeutic alliance, providing patient education and self- management support, selecting appropriate treatment, and monitoring the patient for treatment response, side effects, functional status, adherence, risk of harm to self or others, and co-occurring psychiatric and medical comorbidities [43; 62; 140; 141].
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