Depression Full Guideline

8/6/2019 Depression Full Guideline

1/16

Depression (MDD) Diagnosis and Management

Effecive Dae: June 1, 2004

Scpe

This guideline, adapted rom recent guidelines developed by the Canadian Network or Moodand Anxiety Treatments and the Canadian Psychiatric Association,1,2 summarizes the currentrecommendations or diagnosis and treatment o major depressive disorder (MDD) in primary care andprovides tools to assist physicians with the management o depression.

This guideline applies only to adults between the ages o 19 and 65 and should not be extrapolatedto children, adolescents or geriatric populations. Both presentation and treatment o major depressive

disorder may dier in these populations.

The level o evidence or each recommendation is indicated in brackets:

Level 1 Supported by meta-analysis or replicated, large sample randomized controlled trials

Level 2 Supported by at least one randomized controlled trial

Level 3 Supported by nonrandomized studies or expert opinion

Summary recommendation Care bjecives

Depending on the type o depression and treatment required, these care objectives may be more orless dicult to achieve. There may also be circumstances where the patients condition (comorbidity,chronicity, treatment-resistance) means that more limited care objectives will take priority over thetargets and goals listed here. Thereore, treatment goals must be tailored to the individual.

See Table on page 2.

BRITISH

COLUMBIA

MEDICAL

ASSOCIATION


2/16Depression (mDD) DiagnosisanD management

Care Strategy Targets and Goals

Identication o patients at risk Two quick question screen or high-risk patients Early detection o Major Depressive

(during routine visits). Disorder (MDD)

Diagnosis and assessment Use SIGECAPS mnemonic or symptom Chart record o SIGECAPS responses and

o severity criteria, dierential diagnosis. PHQ-9 scores or patients positive on two

quick question screen.

Use symptom-based rating scale (PHQ-9) Review o medications, medicalto establish baseline. conditions that may cause

depression.

Sel-management Assess and discuss sel-management goals, Inormed patient who is actively involved

challenges and progress. in care decisions. Mutually acceptable

management plans.

Provide patient education and sel-management Chart record o sel-management goals.

materials plus community resources list.

Suicide risk assessment Assess suicide risk at each visit. Identication o patients at high-risk o

suicide and documentation o

management plan.

Post discharge care See patients discharged rom hospital with Chart record o ollow-up visit within 7

diagnosis o MDD. days o discharge.

Acute treatment: Selection Consider patient preerences and availability Treatment without delay.

o resources when selecting treatment. Evidence-based treatment o appropriate

intensity and duration.

Provide adequate dose/duration o rst-line Treatment matched to patients

antidepressants. preerences.

Provide or reer to rst-line psychotherapies.

Acute treatment: Monitoring Plan ollow-up visits. At least three ollow-up visits in rst

12 weeks o antidepressant treatment.

Monitor response, side eects and adherence to At least one ollow-up visit in rst

treatment. 12 weeks o psychotherapyAssess symptoms using PHQ-9 at each visit. Goal: Full remission o symptoms

(PHQ-9 < 5).

Managing poor/incomplete Review treatment plan and modiy i Treatment plan reviewed and modied

response no response to antidepressants ater 3-4 weeks. as needed. Psychiatric reerral i

warranted.

Patients identied or long-term ollow-up.

Maintenance treatment Encourage adherence to continued treatment Continued antidepressant treatment or 6

even ater remission. months ater remission, at least 2 years

or those with risk actors.

Discuss relapse risk actors, symptoms and Follow-up visits during maintenance.

prevention. PHQ-9 at least once a year.

Discuss and plan gradual discontinuation o Goal: Prevention o relapse and

antidepressants. recurrence.

Social network Discuss need or social network o riends and Recognition o early warning signs

amily. and impending crisis. Ongoing support.



recommendation 1 Deeci

a) For patients at high-risk o MDD, use the two quick question screening method:

In the past month:Have you lost interest or pleasure in things you usually like to do?Have you elt sad, low, down, depressed or hopeless?

An answer o Yes to eiher question should trigger a more detailed assessment. [Level 2]

Idividas a Hih-Ris fr MDD[LeveL 1]

chronic insomnia or atigue chronic pain multiple or unexplained somatic complaints, thick charts chronic medical illnesses (e.g., diabetes, arthritis) acute cardiovascular events (myocardial inarction, stroke) recent psychological or physical trauma other psychiatric disorders

amily history o mood disorder

b) Depression may present dierently in special populations. For example, some cultural groups mayocus primarily on physical symptoms. [Level 3]

recommendation 2 Diasis

a) The diagnosis o MDD is based on criteria rom the DSM-IV-TR. The symptom criteria can berecalled using the SIGECAPS mnemonic (see below). A diagnostic questionnaire such as thePHQ-9 (Appendix 1) can also be helpul to identiy key symptoms. [Level 2]

b) In the dierential diagnosis, look or symptoms o an anxiety disorder, bipolar disorder

(hypomania/mania), psychosis, alcohol and substance abuse. Collateral inormation rom amilyor riends is very helpul in making the diagnosis. [Level 3]

c) In the dierential diagnosis, look or medical conditions that may cause or exacerbatedepression by perorming a history, physical exam, and selected laboratory tests as indicated.Review medications to identiy any that may exacerbate depressive symptoms.

SiGecaPS memic frSympm Crieria fr Majr Depressive Episde

Must have depressed mood (or loss o interest) and at least 4 other symptoms, most o thetime, most days, or at least 2 weeks.

S sleep disturbance (insomnia, hypersomnia)I interest reduced (reduced pleasure or enjoyment)G guilt and sel-blameE energy loss and atigueC concentration problems

A appetite changes (low appetite/weight loss or increased appetite/weight gain)P psychomotor changes (retardation, agitation)S suicidal thoughts



recommendation 3 Assessme f sicide ris

Assess suicide risk regularly throughout the course o treatment. Include consultation with amily andriends where appropriate. Be aware that agitation and suicide risk may increase early in treatment.[Level 3]

SuICIDE RISk ASSESSMEnt

Adapted rom Rubenstein, Unutzer, Miranda et al, 1996 3 [Level 3]

Ask all depressed patients i they have thoughts o death or suicide, or i they eel hopeless andeel that lie is not worth living. Also ask i they have previously attempted suicide.

I the answer is yes, ask about plans or suicide. How much have they thought about suicide?Have they thought about a method? Do they have access to material required or suicide?Have they said goodbyes, written a note or given away things? What specic conditions wouldprecipitate suicide? What is stopping them rom suicide?

Assess risk actors or suicide (see below).

Consider emergency psychiatric consultation and treatment i: Suicidal thoughts are persistent The patient has a prior history o a suicide attempt or a current plan, or The patient has several risk actors or suicide

RISk FACtoRS FoR SuICIDE

Psychscia Hisry Ciica/Diasic

First Nations Prior suicide attempt HopelessnessMale Family history o suicide Psychosis

Advanced age Family history o substance Medical illnessSingle or living alone abuse Substance abuse

recommendation 4 Disease maaeme

For many patients, depression can be considered a recurrent and/or chronic condition. Organizationalinterventions within a chronic disease management (CDM) program, such as registration, recall andregular review, can improve the care o patients with depression. [Level 1]

Physicians are encouraged to:

Identiy all patients with depression in their practice Participate in patient registries (local or provincial) whenever possible Use a fow sheet* or each patient with depression Use recall systems to ensure that patients with depression are seen at appropriate intervals Review patient records to ensure that treatment objectives are met

* A fow sheet is a short orm that gathers all important data regarding a patients depressiontreatment. Attached to the patients chart, the fow sheet serves as a reminder and a record owhether treatment objectives have been met. See attached fow sheet.



recommendation 5 Sef-maaeme

a) Involve patients in the management o their own illness by engaging them in discussion about thediagnosis and treatment options, developing a goal-oriented treatment plan, and monitoring orresponse and signs o relapse/recurrence (see patient inormation sheet). [Level 2]

b) When appropriate, use education and sel-management resources, including available community

resources and sel-help agencies. Note: some patients, especially those with more severesymptoms, may not be able to take advantage o sel-management while acutely ill. [Level 2]

SElF-MAnAgEMEnt RESouRCES

Recommend bibliotherapy or depression, e.g., sel-help workbooks; in particular, the Sel-Care Depression Patient Guide, developed at UBC, ree download rom www.mheccu.ubc.ca/publications

Other sel-help workbooks include The Feeling Good Handbookby David D. Burns, Plume Books,1999, about $30; and Mind Over Mood by Dennis Greenberger and Christine A. Padesky, ZipperBooks, about $40.

BC Partners or Mental Health and Addictions Inormation: provides Mental Disorders,Depression and Anxiety Disorders Toolkits. www.heretohelp.bc.ca

Chronic Disease Sel-Management Program: a patient education program oered incommunities throughout British Columbia, which teaches practical skills on managing chronichealth problems. www.coag.uvic.ca/cdsmp

Recommend consumer and sel-help organizations, including the Canadian Mental HealthAssociation (Tel: 1 800 555-8222; www.cmha-bc.org) and the Mood Disorders Association oBC (Tel: 604 873-0103; www.mdabc.net).

recommendation 6 Ace reame

a) The goal o acute treatment is ull remission o symptoms (e.g., PHQ-9 < 5) and return topremorbid psychosocial unction. [Level 1] Treatment selection should consider patient preerencesand availability o resources.

b) In patients with mild to moderately severe MDD, evidence-based psychotherapies are as eectiveas antidepressant medications. For most patients, combined treatment with pharmacotherapyand psychotherapy is no more eective than either therapy alone. Combined treatment should beconsidered or patients with chronic or severe episodes, patients with co-morbidity, and patientsnot responding to monotherapy. [Level 1]

c) First-line psychotherapies include cognitive behavioural therapy (CBT), interpersonalpsychotherapy (IPT) and problem-solving therapy (PST). [Level 1] See Appendix 2. For most amilyphysicians, this will mean reerral to a psychotherapist with appropriate training.

Note: I another health proessional delivers psychotherapy, there must be regular communicationabout the patients progress, especially i medications are also used.

d) Even i ormal psychotherapy is not used, patients can benet rom supportive management byphysicians, especially in conjunction with medication treatment. [Level 2]



Spprive Ierveis[Level 2]

Arrange regular ollow-up visits. Use the power o the prescription pad to prescribe one brie walk per day, one nutritious

meal per day, and one pleasurable activity per day. Encourage the patient to keep a simple daily mood chart.

Encourage and promote patient sel-management.

e) Antidepressant medications are also rst choice treatments or MDD in primary care, especially orthose with moderate to severe depressions. [Level 1]

) Many eective rst-line antidepressants are now available with dierent neurochemical actionsand side eect proles (Appendix 3). Most systematic reviews have not shown any clinicallysignicant dierences in ecacy among antidepressants. However, clinical actors that should beconsidered when choosing a medication include: [Level 1]

previous response depressive subtype

comorbid conditions side eects drug-drug interactions short-term remission rates cost

g) Give simple messages about antidepressants to every patient, to promote adherence. [Level 2]

Simpe Messaes Prme Aidepressa Adherece[Level 2]

1. Antidepressants are not addictive.2. Take your antidepressants daily.3. It may take 2 to 4 weeks to start noticing improvement.4. Do not stop antidepressants without talking to your physician, even i eeling better.5. Mild side eects are common, but are usually temporary.6. Call your physician with any questions.

h) Consider the subtype o depression when selecting treatment.

Subtypes of Depression with Treatment Implications

Subtype Key features Treatment consideration

Psychotic depression Presence o hallucinations or Antidepressant + atypical

delusions (especially delusions o guilt). antipsychotic agent, [Level 2] ORelectroconvulsive therapy. [Level 1]

Winter depression Regular onset o depressive episodes during the Bright light therapy OR antidepressant. [Level 1]

(seasonal aective disorder) all/winter with summer remissions.

Postpartum depression Onset o depressive episode within 4 weeks post- Consider breasteeding issues with

partum. May be associated with psychotic eatures. pharmacotherapy. [Level 3]

Depression associated Previous history o manic (type I) or hypomanic Mood stabilizer antidepressant. [Level 2]

with Bipolar Disorder (type II) episodes.



recommendation 7 Miri cmes

a) MDD is oten a chronic or recurrent condition that requires close initial monitoring untilsymptoms are eliminated and then periodic monitoring to make sure a relapse or recurrencedoes not occur. [Level 3]

b) Use a validated measure o patient outcome, such as the PHQ-9 (Appendix 1), to evaluate

response. [Level 2]

c) Follow up with patients at least weekly or biweekly, depending on severity, until patients showclear improvement. Visits can then be reduced to monthly or less oten, depending on individualcircumstances. Like other patients with chronic conditions, depressed patients can benet romregularly scheduled visits. [Level 3]

d) For antidepressant treatment, expect the usual trajectory o response: initial mild symptom improvement (e.g., > 20% improvement in PHQ-9) within 2-4 weeks good clinical response (e.g., > 50% improvement in PHQ-9) within 4-8 weeks remission o symptoms (e.g., PHQ-9 < 5) by 8-12 weeks.

Remission o symptoms by 12-16 weeks is a realistic goal in about 65% o all patients with MDD.Recovery o baseline unction may take longer. [Level 1]

e) Patients reerred or psychotherapy or engaging in sel-management programs should also bemonitored or treatment response at monthly or bimonthly intervals. [Level 3] For psychotherapytreatment, expect clinical improvement within 6-8 weeks and remission o symptoms by 12-16weeks.

recommendation 8 Maieace reame

a) The goal o maintenance treatment is to prevent relapse and recurrence. [Level 1]

b) Continue patients on antidepressants or at least 6 months ater a ull remission o symptoms. Usethe same antidepressant dosage in the maintenance phase as in the acute phase. [Level 1]

c) Patients with high-risk actors or recurrence require longer maintenance treatment at least2 years, and, or some, lietime (based on individual assessment o ongoing risk andtolerability). [Level 1]

d) When discontinuing an antidepressant, the physician should taper the medication slowly to avoiddiscontinuation symptoms. Education about early signs o relapse should continue (e.g. recurrenceo SIGECAPS symptoms or increase in PHQ-9), and patients should have regular ollow-ups every2-3 months or the rst 6 months. Psychotherapy (see Recommendation 6) is helpul and sel-management programs (see Recommendation 5) may be helpul to prevent relapses. [Level 2]

Ris Facrs Idicai ler-term(a eas 2 years) Aidepressa Maieace [leve 1]

chronic episodes (> 2 years duration) severe episodes (suicidality, psychosis) resistant or hard-to-treat episodes requent episodes (2 episodes in past 2 years) recurrent episodes (3 or more lietime episodes) age > 65 years-o-age



recommendation 9 Maaeme f pr r icmpee respse

a) I treating with antidepressants, at least minimal response (greater than 20% reduction indepression scores) or partial response should occur ater 3-4 weeks o treatment at a therapeuticdose. I there is no response, the antidepressant dose should be increased every 2-4 weeks untilresponse occurs, maximum approved dose is reached, or limiting side eects are experienced.

b) I treating with psychotherapy produces poor or incomplete response, add antidepressants.

Maaeme opis fr Iadeqae r Icmpee Respse Maximized Dse f Aidepressa

Re-evaae diagnostic issues (e.g., mania/hypomania, depressive subtypes, medical orpsychiatric comorbidity, alcohol and substance abuse, personality traits/disorders).

Re-assess treatment issues (e.g., compliance, side eects).

Add psychotherapy. [Level 2] See Recommendation 5.

Swich to another antidepressant in the same class (i on SSRI) or in a dierent class. [Level 2]

See Appendix 4. Ame with lithium [Level 1], triiodothyronine (T3) [Level 2] or an atypical antipsychotic agent. [Level 3]

Second line augmentations include buspirone, tryptophan or stimulants. [Level 3]

Cmbie with another antidepressant in a dierent neurochemical class. [Level 3]

Refer to a specialist or community mental health centre. Clinical situations that warranta psychiatric reerral include: severe depressive symptoms (active suicidality, psychosis);diagnostic uncertainty; signicant psychiatric/medical co-morbidity; and unsatisactoryresponse to adequate trials o two or more antidepressants. [Level 3]

Raiae

The health, nancial and social burdens associated with depression are proound: 1.4 million peoplein Canada aficted at any given time; over $3 billion in direct medical costs; 40,000 person-yearslost rom work and over $1 billion in associated economic costs; the second leading medical causeo long-term disability; the ourth leading cause o global burden o disease (predicted to be secondleading cause by 2020).4 Mortality rates are high: approximately 4% o people with a mood disorderdie by their own hand and at least 66% o all suicides are preceded by depression.5 Depression is alsoassociated with increased rates o death and disability rom cardiovascular disease.5,6

Depression is commonly encountered in primary practice, but requently under-diagnosed. TheWHO Psychological Problems in General Health Care study ound that only 42% o patients withmajor depression were diagnosed appropriately by their primary care physician.7 Depression is otenmissed in people with chronic illness, those who present with somatic symptoms, teens and the

elderly.8

Recognition is hampered by the act that many depressed patients present with non-specicphysical complaints, without spontaneously divulging the psychological nature o their problems.9Recognizing high-risk patients and using simple screening and diagnostic tools can improve detectiono depression in primary practice.

Once diagnosed, depression may be eectively treated with antidepressants, certain orms opsychotherapy, or both.10 Antidepressant medications are clinically eective across the ull rangeo severity o major depressive disorders. Specic orms o time-limited psychotherapy (cognitivetherapy, interpersonal therapy) are as eective as antidepressants or mildly to moderately severemajor depressive disorder.11,12 However, even when depression is recognized and treated, treatment isoten provided ineectively in a manner inconsistent with current evidence.13


9/16



10

The principles o the Guidelines and Protocols Advisory Committee are:

to encourage appropriate responses to common medical situations

to recommend actions that are sucient and ecient, neither excessive nor decient to permit exceptions when justied by clinical circumstances.

g&p00-0

10. To A, Oetter H, Lam RW. Treatment o depression in primary care. Part 1. Principles o acutetreatment.Part 2. Principles o maintenance treatment. BCMJ 2002;44(9):473-484.

11. Olson M, Marcus SC, Druss B et al. National trends in the outpatient treatment o depression.National trends in the outpatient treatment o depression.JAMA 2002;287(2):203-209.

12. Segal ZV, Whitney DK, Lam RW. Clinical guidelines or the treatment o depressive disorders. III.Psychotherapy. Can J Psychiatry2001;46(Suppl 1):29S-37S.

13. Michalak EE, Goldner EM, Jones W, Oetter H, Lam RW. The management o depression in

primary care: current state and a new team approach. BCMJ 2002;44(8): 408-411.14. Katon W, Rutter C, Ludman EJ et al. A randomized trial o relapse prevention o depression inA randomized trial o relapse prevention o depression in

primary care.Arch Gen Psychiatry2001; 58(3):241-7.15. Greden JF. Clinical prevention o recurrent depression. The need or paradigm shits. In:

Treatment o Recurrent Depression. Review of Psychiatry2001;20(5):143-169.16. Andrews G. Should depression be managed as a chronic disease? BMJ 2001;322:419-421.17. Badamgarav E, Weingarten SR, Henning JM et al. Eectiveness o disease management

programs in depression: A systematic review.Am J Psychiatry2003;160(12):2080-2090.18. British Columbia Provincial Depression Strategy. Phase 1 Report, October 2002.

www.health.gov.bc.ca/mhd/pd/depressionstrategy.pd

Spsrs

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the

British Columbia Medical Association and adopted by the Medical Services Commission.

Funding or this guideline was provided in ull or part through the Primary Health Care Transition Fund.

Revised Dae: April 1, 2007This guideline is based on scientic evidence current as o the eective date.

Guidelines and Protocols Advisory CommitteePO Box 9642 STN PROV GOVT

Victoria BC V8W 9P1

Phone: (250) 952-1347 E-mail: [email protected]

Fax: (250) 952-1417 Web site: BCGuidelines.ca



11

1. Appedix 1. Paie Heah esiaire PH- (www.primary-care.r)Appedix 1. Paie Heah esiaire PH- (www.primary-care.r)

PATIENT NAME DATE

Over the last 2 weeks, how oten have you been bothered by any o the ollowing problems ?

Not at Several More than hal Nearly every

all (0) days (1) the days (2) day (3)

Little interest or pleasure in doing things.

Feeling down, depressed, or hopeless.

Trouble alling/staying asleep, sleeping too much.

Feeling tired or having little energy.

Poor appetite or overeating. Feeling bad about yoursel, or that you are a ailure,

or have let yoursel or your amily down.

Trouble concentrating on things, such as reading the

newspaper or watching TV.

Moving or speaking so slowly that other people

could have noticed; or the opposite: being so dgety

or restless that you have been moving around more

than usual.

Thoughts that you would be better o dead or o

hurting yoursel in some way.

I you checked o any problem on this questionnaire so ar, how dicult have these problems made it or you to do

your work, take care o things at home, or get along with other people?

Not dicult at all Somewhat dicult Very dicult Extremely dicult

TOTAL SCORE:

a)

b)

c)

d)

e)

)

g)

h)

i)

a)

2.

1.



1

Isrcis Hw t Scre the PH-

Majr depressive disrder is sesed if: O the 9 items, 5 or more are checked as at least more than hal the days Either item a. or b. is positive, that is, at least more than hal the days

oher depressive sydrme is sesed if: O the 9 items, a., b. or c. is checked as at least more than hal the days Either item a. or b. is positive, that is, at least more than hal the days

Also, PHQ-9 scores can be used to plan and monitor treatment. To score the instrument, tally eachresponse by the number value under the answer headings, (not at all=0, several days=1, more thanhal the days=2, and nearly every day=3). Add the numbers together to total the score on the bottomo the questionnaire. Interpret the score by using the guide listed below.

gide fr Ierprei PH- Scres

Scre Aci

0-4 The score suggests the patient may not need depression treatment

5-14 Mild major depressive disorder. Physician uses clinical judgment abouttreatment, based on patients duration o symptoms and unctional impairment.

15-19 Moderate major depressive disorder. Warrants treatment or depression,using antidepressant, psychotherapy or a combination o treatment.

20 or higher Severe major depressive disorder. Warrants treatment with antidepressant,with or without psychotherapy; ollow requently.

Fcia Heah Assessme

The instrument also includes a unctional health assessment. This asks the patient how emotionaldiculties or problems impact work, things at home, or relationships with other people. Patientresponses can be one o our: Not dicult at all, Somewhat dicult, Very dicult, Extremely dicult.The last two responses suggest that the patients unctionality is impaired. Ater treatment begins,unctional status and number score can be measured to assess patient improvement.

Fr frher ifrmai he PH-:Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity o a brie depression severity measure.J GenIntern Med 2001;16: 606-613.



1

Psychherapy geera Pricipes leh ftherapy

Resrces fr Psychica treame i BC

1. Private psychiatrists by reerral.

2. Private psychologists, particularly those with CBT training; the BC PsychologicalAssociation (604 730-0522) operates a reerral service.

3. Ambulatory Psychiatric Clinics or Day Programs at hospitals, or community MentalHealth Centres.

4. Changeways a best-practice, group-based psychoeducational program or depression, oeredin a number o hospitals and Community Health Centres throughout the province.www.changeways.com

Identiy automatic, maladaptive thoughts and distorted

belies that lead to depressive moods. Learn strategies to modiy these belies and practiceadaptive thinking patterns.

Use a systematic approach to reinorce positive copingbehaviours.

8 to 12

sessions

Cognitive Behavioral

Therapy (CBT)

InterpersonalTherapy (IPT)

Identiy signicant interpersonal/relationship issues thatled to, or arose rom, depression (unresolved grie, roledisputes, role transitions, social isolation).

Focus on 1 or 2 o these issues, using problem-solving,dispute resolution, and social skills training.

12 to 16sessions

Problem-Solving

Therapy (PST)

Use a structured approach to identiy and

actively solve problems that contribute todepression.

6 to 8

sessions

Appedix 2. Firs-ie psychherapies fr reame f depressiAppedix 2. Firs-ie psychherapies fr reame f depressi [leve 1]



1

Appedix 3. therapeic dses & css f cmmy prescribed aidepressas [leve 1]

Aidepressa usa Daiy Dse (m) Cs Per Day ($)

Firs lie Aidepressas

nve acibupropion-SR 150-300 0.88-1.54mirtazapine 30-60 1.33-2.66trazodone 200-400 0.84-1.68RIMAmoclobemide 450-600 1.17-1.53SnRIvenlaaxine-XR 75-225 1.73-5.19

SSRI

citalopram 20-40 0.94-1.88fuoxetine 20-40 1.08-2.16fuvoxamine 100-200 0.95-1.90paroxetine 20-40 1.18-2.36sertraline 50-150 1.07-3.211.07-3.21

Secd lie Aidepressas

tCAamitriptyline 100-250 0.32-0.80clomipramine 100-250 0.86-2.15

desipramine 100-250 0.92-2.28imipramine 100-250 0.66-1.65nortriptyline 75-150 0.77-1.63

third lie Aidepressas

MAoI*phenelzine 30-75 0.74-1.86tranlycypromine 20-60 0.73-2.20

* Use with caution because o dietary restrictions and drug-drug interactions

Data adapted rom the BC Drug Formulary and the Manuacturers list (2001)

RIMA = Reversible monoamine oxidase inhibitor TCA = Tricyclic antidepressantSNRI = Serotonin and norepinephrine reuptake inhibitor MAOI = Monoamine oxidase inhibitorSSRI = Selective serotonin reuptake inhibitor



1

Appedix 4. Wash recmmedais fr swichi aidepressas

Adapted rom Guidelines or the Diagnosis and Pharmacological Treatment o Depression.Toronto, ON, Canadian Network or Mood and Anxiety Treatments, 1998.

SSRI nve tCA RIMA MAoI

SSRI No washout No washout No washout 1 week 1 week No washout No washout No washout 1 week 1 week

citalopram

fuoxetine May have additive May have additive Start TCA at a (5 wks or 5 wks orMay have additive May have additive Start TCA at a (5 wks or 5 wks or

fuvoxamine serotonergic side serotonergic side lower dose fuoxetine) fuoxetine)serotonergic side serotonergic side lower dose fuoxetine) fuoxetine)

paroxetine eects or 1 week eects or 1 week eects or 1 week eects or 1 week

sertraline (5 wks or fuoxetine) (5 wks or fuoxetine) Some SSRIs can(5 wks or fuoxetine) (5 wks or fuoxetine) Some SSRIs can

increase serum

TCA levels orTCA levels or

1 week (5 wks orfuoxetine)

NOVEL

bupropion-SR No washout No washout No washout 1 week 1 week

mirtazapine

venlaaxine-XR May have additive May have additive

serotonergic side serotonergic side

eects or 1 week eects or 1 week

TCA

desipramine No washout No washout No washout 1 week 1 week

nortriptylineamitriptyline Serum TCA levels

imipramine may be increased

others by some SSRIs

or 1 week

RIMA

moclobemide 3 days 3 days 3 days N/A 3 days

MAOI*

phenelzine 2 weeks 2 weeks 2 weeks 2 weeks 2 weeks

tranylcypromine

SWItCH FRoM

* Use with caution because o dietary restrictions and drug-drug interactions

RIMA = Reversible monoamine oxidase inhibitor TCA = Tricyclic antidepressantSNRI = Serotonin and norepinephrine reuptake inhibitor MAOI = Monoamine oxidase inhibitorSSRI = Selective serotonin reuptake inhibitor

SWItCH to


16/16

DEPRESSIonPAtIEnt CARE FloW SHEEt

NAME OF PATIENT BIRTHDATE

PHNCOMORBID CONDITIONS

DIAGNOSIS

HltH-BCMA 6004 (Rev 2007)

AC

UTETREA

TMENT

(8-16WE

EKS)

DAtE (YY/MM/DD)

TELEPHONE NUMBER

Medication/Dose

Reerral made

Assessed

Reerral made

Ongoing

Q2 Result

W (weekly)B (Bi-weekly)O (other)

Y (cont. meds 2 yrs)N (cont. meds 6 mos)

PSYCHOTHERAPY

(CBT/IPT/PST

ANTIDEPRESSANTS

PSYCHIATRY

SUICIDE RISK

PHQ-9

SELF-MANAGEMENT(education/community,resources, socialsupports)

ER VISIT ORHOSPITALIZATION

PLANNED FOLLOW-UP

RISK FACTORS FORRELAPSE

ANTIDEPRESSANTS

PSYCHIATRY

PHQ-9

SELF-MANAGEMENT(incl discussion orelapse prevention)

PLANNED FOLLOW-UP

EMPLOYMENT STATUS

Employed UnemployStudent Retired Homemaker

Mania/Hypomania Past suicide attempt Anxiety disorderAlcohol/drugs

Other: _______________________

Single episode Recurrent episode Chronic episode

MEDICAL: Respiratory Neurological disorder Cancer Hypertension Other endocrineDiabetes Kidney disease Arthritis Heart disease Liver disease

Other: _______________________

Ongoing

Side eects monitored

PSYCHIATRIC:

Management plandocumented

Follow-up visit(within 7 days)

MA

INTENAN

CETREA

TMENT(6

M

OS-2

YRSOR

LONGER

)

Medication/Dose

Side eects monitored

Reerral made

Ongoing

Goals set and/orreviewed

Q1 Score

Goals set and/orreviewed

M (monthly)6 (6 mos)O (other)

Tapering Plan

(discont symp discussed)

Q1 Score

Q2 Result

(Remission:

Documents

Depression Full Guideline