Depression : Clinical Practice Guidelines

WHOM TO SCREEN Management of Depression

•Adolescents 12-18 y MILD Depression

and initiation of therapy and then every 2-4

weeks until there is remission or response
Follow up should be 1 wk. after diagnosis
•Adults older that 18 years
•PHQ-9 Score 5-9 points
•Pregnant women at least once
•Psychotherapy alone and/or behavioural activation

ACUTE PHASE (6-12 WEEKS)

during perinatal period
•Postpartum Women
•Geriatric population MODERATE Depression
•Patients with Chronic Medical •PHQ-9 score 10-19 points
Conditions •Psychotherapy alone, or pharmacotherapy
WHEN TO SCREEN alone or combination therapy
Screening

•New patient visits SEVERE Depression

•Annual preventive visits
•PHQ-9 score 20-27
•Any visit if not done in the previous •Pharmacotherapy or combination therapy or ECT
90 days

SCREESING TOOLS Box1 ASSESS INITIAL RESPONSE, USE PHQ-9

At 4-6 weeks if on Pharmacotherapy (alone or in

combination) or 6-12 weeks if psychotherapy alone
PHQ 2, If score is >3, it is a + screen

RESPONSE
PHQ 9, A score ≥ 10 points requires Asses in 4-6
wks. using
further clinical evaluation PHQ9 score
YES NO

Diagnosis of Major Depression

Requires ≥5 of the following Adjust Medications until STEPPED CARE

•Follow up every 1-3 months

Symptoms for >2 weeks: SIG ME remission is achieved APPROACH

CONTINUTION PHASE
CAPS • Assess compliance/
Continue medication 4-9 adherence
S: Sleep changes months once remission • Adjust medication
I: Loss of interest (anhedonia) is achieved dose

•(4-9 MONTHS)
G: Feelings of guilt • Increase number of
Assess response every 1- therapy sessions
Diagnosis

M: Depressed mood 2 months using PHQ-9 • Augment or change

E: Poor Energy therapy type
C: Poor concentration • Referral to
A: Appetite or weight change Behavioural health
P: Psychomotor changes
MAINTENANCE PHASE

S: Suicidality, Thoughts of death

NOTE: M and Or I must be present. HIGH RISK FOR RECURRENCE
1 year to Lifetime

Don’t include symptoms that are

clearly due to GMC. NO YES
Symptoms do not meet criteria for •Discontinue Treatment •Continue
Mixed episode •Taper antidepressants Pharmacotherapy
over several weeks •Follow should be
every 3-12 months if
BOX1: SCREENING TOOLS
stable
•PHQ2 & PHQ9 RISK FACTORS FOR RECURRENCE
•Edinburgh Postnatal Depression scale : 3 or more major depressive episodes or 2 prior episodes and any of the
postpartum females following factors:
• The Geriatric Depression Scale 5, 15 or 30 item • Chronic major depressive disorder
questionnaire: elderly • Ongoing Psychological Presence or residual symptoms
• The Cornell scale: patients with dementia • Early age at onset
• Family history of Mood disorders
 Pharmacotherapy
•SSRIs are the most widely prescribed class of antidepressants, Choice depend on :adverse effect profile/ Safety, Patient
preference, History of prior response to specific medication, Response of first degree relative to specific medication, Cost,
Specific depressive symptoms, Co-morbid illnesses, Concurrent medications and potential drug-drug interaction
SWITCHING BETWEEN DRUGS AND CLASSESS
•Switching between SSRI : substitute new SSRI at equivalent dose of former SSRI
• Switching from SSRI to SNRI :Cross taper or switch to equivalent dose: Venlafaxine 75mg, Duloxetine 60mg
(Dose of current antidepressant in reduced over several weeks, while dose of new antidepressant is increased)
CONSIDER REFERRAL TO BEHAVIOURAL HEALTH AT ANYTIME IF:
•Depression that endangers life of the patient or others, Suicidality and/or Homicidally
•Depression that occurs in the context of Bipolar disorder, Schizoaffective disorder or Schizophrenia
•Psychiatric co-morbidity (i.e. substance abuse, OCD, anxiety, eating disorders)
•No improvement with medications despite multiple dose adjustments and trials of different medication classes
•Significant or prolonged inability to work and care for self and/ or family
•Diagnostic uncertainty
•Severe Psychotic and Catatonic depression

SSRI( selective serotonin reuptake inhibitors (Citalopram, Escitalopram, Fluoxetine, paroxetine, sertraline
Indications : Depression , GAD, Obsessive-compulsive disorder
Contraindications: poorly controlled epilepsy, mania. Escitalopram ( prolonged QT-interval)
Cautions: cardiac disease, DM, history of GI bleeding, history of mania, susceptibility to angle –closure glucose. Risk of
significant hyponatremia in elderly Side effects: COMMON: anxiety, appetite abnormal, arrhythmias, arthralgia, impaired
concentration, confusion, constipation/diarrhea, dry mouth, drowsiness, fever, GI discomfort, headache, hyperhidrosis,
memory loss, menstrual cycle irregularities, sexual dysfunction, sleep disorders, tinnitus, tremor, weight change ,yawning,
Sinusitis ( Escitalopram). Fluoxetine(postmenopausal bleeding) Sertraline( increased risk of infection, neuromuscular
dysfunction) UNCOMMON& RARE: alopecia, mania, movement disorder, postural hypotension, suicidal tendency, syncope,
photosensitivity, seizure, galactohrea, hepatitis, serotonin syndrome, SIADH, Fluoxetine ( dyspnea, muscle twitching,
dysphagia, vasculitis, bone fracture). Sertraline( conversion disorder, diabetes, hypothyroidism, drug dependence, genital
discharge, hiccups, myocardial infarction, peripheral ischemia)
Pregnancy & Breast feeding: Use with caution . Liver impairment: reduce dose. Renal impairment : caution if eGFR≤30
Treatment cessation : withdrawal effects may occur within 5 days of stopping treatment, usually mild and self limiting. The
risk is increased if stopped suddenly after regular administration for 8 weeks. Advice to reduce dose gradually over 4-6 weeks
or longer. Withdrawal effect: headache , GI disturbances, dizziness, sleep disorders , fatigue, flu like symptoms, palpitations
Dose: Escitalopram : 10mg daily increase up to 20 mg , half dose in elderly . Fluoxetine: 20 mg daily increase every 4 weeks
up to 60 mg daily. . Paroxetine: 20mg in the morning , no evidence of greater efficacy at higher doses
Sertraline: 50mg daily, increase weekly up to maximum of 200 mg daily

SNRI( serotonin- norepinephrine reuptake inhibitors (Venlafaxine, Duloxetine)

Indications : depression , GAD, menopausal symptoms mainly hot flushes in women with breast cancer, Duloxetine ( diabetic
neuropathy , stress incontinence in females). Cautions: similar to SSRI Contraindications: Venlafaxine ( uncontrolled
hypertension) Side effects: Similar to SSRI. Pregnancy & Breast feeding: use with caution Liver impairment: avoid duloxetine
, ½ dose venlafaxine Renal impairment : avoid duloxetine if eGFR≤30, use ½ dose venlafaxine Treatment cessation :
withdrawal effects may occur. Advice to reduce dose gradually over 1-2 weeks or longer Dose: Venlafaxine: 37.5mg daily
increase after a week to 75 mg, if needed increase every 2 weeks up to 225mg daily Duloxetine: 60 mg daily. For diabetic
neuropathy stop in 2 months if no response. 20-40mg twice daily for stress incontinence , review response in 4 weeks

Trazodone (Serotonin modulators) Mirtazapine ( Atypical agents )

Indications : depression , anxiety Cautions: similar to SSRI, Indications : depression Cautions: similar to SSRI Side effects: anxiety,
risk of suicide, prostate hypertrophy. Contraindications: weight gain , arthralgia, back pain, confusion, constipation, diarrhea ,
mania, immediate recovery period after MI. Side effects: dry mouth , fatigue, sleep disorders Pregnancy : avoid Breast
aggression, agranulocytosis, anemia, aphasia, abnormal feeding: Avoid Liver impairment: avoid Renal impairment : reduce
apatite, arrhythmias, arthralgia, chest pain, confusion, dose Treatment cessation : withdrawal effects may occur. Advice to
delusions, dyspnea, dry mouth , fever, headache, reduce dose gradually over several weeks. Dose: 15-30mg daily for 2-4
hyponatremia, flue like symptoms, jaundice , hypertension, weeks at bedtime up to 45 mg
hyper salivation, memory loss, edema, paralytic ileus, tremor,
weight loss Pregnancy : avoid during 1st trimester. . Breast
feeding: can be used. Liver impairment: caution Renal Tricyclic antidepressants ( amitriyline, clomipramine, imipramine,
impairment use with caution. Treatment cessation : Dosulepin). Monoamine oxidase inhibitors ( phenelzine, Selegiline):
withdrawal effects may occur. Advice to reduce dose are typically not used as initial treatment as concerns about safety
gradually over 4weeks . Dose: 150 mg daily in divided doses (particularly in overdose) & adverse effects.
after food or 150 mg once at bedtime. Can be increased up to
300mg daily. Start with 100 mg in elderly. References:
American Academy of Family Physicians
American Psychiatry Association
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