Depression and Suicide _ ______________________________________________________________________
Psychotherapy Treatment Recommendations For patients with moderate-to-severe depression, a combina- tion of antidepressant medication and CBT or interpersonal therapy should be provided. The choice of intervention should be influenced by the duration of the episode of depression and symptom trajectory, previous course of depression and treatment response, likelihood of adherence to treatment, any potential adverse effects, and individual treatment prefer- ence and priorities [68]. A 2017 evaluation of whether CBT response was influenced by baseline depression severity sug- gested that patients with MDD can expect as much benefit from CBT across the wide range of illness severity [155]. For patients with persistent subthreshold depressive symptoms or mild-to-moderate depression who decline an antidepressant, CBT, or interpersonal therapy, consider counseling. Short-term psychodynamic psychotherapy should be offered to patients with mild-to-moderate depression. Individual CBT is an option for patients who have either relapsed despite antidepressant medication or have a significant history of depression and residual symptoms despite treatment and are unable or unwill- ing to continue antidepressant treatment. Mindfulness-based cognitive therapy should be offered to patients who are cur- rently remitted but have experienced three or more previous episodes of depression [68]. Psychotherapy is preferred as a first-line treatment for elderly patients because of potential increased toxicity and drug-drug interactions. The evidence does not support superiority of one psychotherapy modality over another in elderly patients with MDD [64]. PHARMACOTHERAPY Treatment with antidepressant medications can involve dosage adjustments and/or trials of a different medication at some point to maximize response and minimize side effects [22]. Patient adherence to the medication regimen is essential in achieving the maximum clinical benefit. Strategies to enhance adherence are discussed below. Patient education regarding the treatment plan should include when and how often to take medication; the anticipated two- to four-week lag before beneficial effects may be noticed; the need to continue medi- cation even after feeling better; what to do if problems arise; and the importance of tapering antidepressants before discon- tinuing them [22]. Providers should closely monitor patients for worsening depressive symptoms and emergent suicidality; appropriate intervention includes stopping or modifying the drug therapy or hospital admission [21]. Providers should instruct patients and caregiver(s) to be alert for emerging agitation/irritability, suicidality, and worsening depression, and to report this immediately to a healthcare provider [21]. An antidepressant medication is indicated for initial treat- ment of patients with mild to moderate depressive disorder. The effectiveness of antidepressants is comparable between and within classes of medications, including TCAs, SSRIs and other second-generation agents (e.g., SNRIs, bupropion),
attempting to change them. With practice, patients can become more detached from dysfunctional thoughts by observing them as objects [64]. Interpersonal Psychotherapy Derived from attachment theory, interpersonal psychotherapy focuses on improving interpersonal functioning and exploring relationship patterns. It addresses the connection between patients’ feelings and current relationship difficulties by target- ing four primary areas: interpersonal loss, role conflict, role change, and interpersonal skills [64]. Short-Term Psychodynamic Psychotherapy Derived from longer-term psychoanalysis and psychodynamic psychotherapy, short-term psychodynamic psychotherapy assists patients in gaining insight into unconscious conflicts as they manifest in daily life and relationships, including the therapeutic relationship (i.e., transference). This approach considers these conflicts to originate in the past, usually child- hood relationships to parental figures. Patients gain insight into and work through such conflicts by exploring their feelings and therapist interpretation [64]. Marital/Family Therapy Marital and family problems are common in mood disorders, and can predate, perpetuate, or develop as consequence to the mood disorder. Marital/family therapy approaches effec- tive in depression treatment include behavioral approaches, problem-focused approaches, and strategic marital therapy. Marital/family therapy is a helpful adjunct to medications and hospitalization in severely ill patients [22]. Complicated Grief Therapy Complicated grief therapy involves history-taking, psychoedu- cation about complicated grief and its treatment, work with memory and pictures, and imagined conversations with the deceased, over a 16-week period. In one study, adults with complicated grief were randomized to combinations of compli- cated grief therapy, citalopram, or placebo. Complicated grief was very much improved with complicated grief therapy; add- ing citalopram had no further benefit. Depressive symptoms showed greater decrease with citalopram added to complicated grief therapy; citalopram response at 20 weeks was comparable to placebo. Suicidal ideation rates showed greatest reduction with complicated grief therapy [75]. Problem-Solving Therapy Problem-solving therapy is a time-limited, structured inter- vention involving therapist-patient collaboration to identify and prioritize problems; break problems down into specific, manageable tasks; problem solve; and develop appropriate coping behaviors for problems. It was developed to specifically address social problem-solving deficits common in chronic depression [151; 152]. Problem-solving therapy is designed for use in primary care settings [153; 154].
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