Chapter 11
Management of Depression
59
, Chapter 11: Management of Depression
1. Biological management.
2. Psychological management.
3. Social management.
1. Biological management of depression
References: (1). NICE Guideline (CG90). Depression in adults: recognition and treatment. Published October 2009.
(2). NICE Advice (KTT8): First-choice antidepressant use in adults with depression or generalised anxiety
disorder. Published January 2015 (last updated February 2016).
(3). The Maudsley Prescribing Guidelines in Psychiatry, 13th edition, 2018.
(4). British Association of Psychopharmacology (BAP) Guidelines 2015. Evidence-based guidelines for
treating depressive disorders with antidepressants: A revision of the 2008 British Association for
Psychopharmacology guidelines. Published 2015.
Introduction
For people with mild depression:
o Antidepressants are not recommended as a first-line treatment in recent onset, mild depression. Active
monitoring, individual guided self-help, CBT and/or exercise are preferred.
o Antidepressants are not recommended for the treatment of mild depression because the risk-benefit ratio is
poor.
For people with persistent sub-threshold depressive symptoms or mild to moderate depression
who have not benefited from a low-intensity psychosocial intervention, consider:
o An antidepressant (normally a selective serotonin reuptake inhibitor [SSRI]), or
o A high-intensity psychological intervention, e.g. CBT, interpersonal therapy (IPT) or couples therapy.
For people with moderate or severe depression:
o Provide a combination of antidepressant medication and a high-intensity psychological intervention (CBT
or IPT).
o When an antidepressant is to be prescribed, it should normally be a SSRI in a generic form because
SSRIs are equally effective as other antidepressants and have a favourable risk-benefit ratio.
o If a person’s depression shows no improvement after two to four weeks with the first antidepressant, check
that the drug has been taken regularly and in the prescribed dose.
o If response is absent or minimal after three to four weeks of treatment with a therapeutic dose of an
antidepressant consider:
Increasing the dose in line with the reference dose range if there are no significant side effects, or
switching to another antidepressant if there are side effects or if the person prefers.
When switching to another antidepressant consider switching:
- Initially to a different SSRI or a better tolerated newer-generation antidepressant.
- Subsequently to an antidepressant of a different pharmacological class that may be less well
tolerated, e.g. venlafaxine, a tricyclic antidepressant (TCA), or a monoamine oxidase inhibitor
(MAOI).
If a person is informed about and prepared to tolerate the increased side effect burden, consider
augmenting an antidepressant with:
A mood stabiliser such as lithium.
An antipsychotic such as aripiprazole, olanzapine, quetiapine or risperidone.
Another antidepressant such as mianserin or mirtazapine.
Duration of treatment:
o Use antidepressants for at least six to nine months for first episode depression or two years for recurrent
depression.
o All patients should be informed about the withdrawal (discontinuation) effects of antidepressants.
Response to treatment:
o There is a 55-70% response rate with antidepressants for acute depression.
o If a person’s depression has not responded to either biological or psychological interventions, consider
combining antidepressants with cognitive behavioural therapy.
Electroconvulsive therapy (ECT) is supported in severe and treatment-resistant depression.
Key points that patients should know about antidepressants
Contrary to the common belief that antidepressants often take 2-4 weeks to start working, there is compelling
evidence that antidepressants at effective doses produce partial improvements within the first two weeks of
treatment (e.g. reduced motor retardation and irritability in addition to initial improvements in mood and sleep).
A single episode of depression should be treated for at least six to nine months after remission.
The risk of recurrence of depressive illness is high and increases with each episode.
Those who have had multiple episodes of depression may require treatment for many years.
60
Management of Depression
59
, Chapter 11: Management of Depression
1. Biological management.
2. Psychological management.
3. Social management.
1. Biological management of depression
References: (1). NICE Guideline (CG90). Depression in adults: recognition and treatment. Published October 2009.
(2). NICE Advice (KTT8): First-choice antidepressant use in adults with depression or generalised anxiety
disorder. Published January 2015 (last updated February 2016).
(3). The Maudsley Prescribing Guidelines in Psychiatry, 13th edition, 2018.
(4). British Association of Psychopharmacology (BAP) Guidelines 2015. Evidence-based guidelines for
treating depressive disorders with antidepressants: A revision of the 2008 British Association for
Psychopharmacology guidelines. Published 2015.
Introduction
For people with mild depression:
o Antidepressants are not recommended as a first-line treatment in recent onset, mild depression. Active
monitoring, individual guided self-help, CBT and/or exercise are preferred.
o Antidepressants are not recommended for the treatment of mild depression because the risk-benefit ratio is
poor.
For people with persistent sub-threshold depressive symptoms or mild to moderate depression
who have not benefited from a low-intensity psychosocial intervention, consider:
o An antidepressant (normally a selective serotonin reuptake inhibitor [SSRI]), or
o A high-intensity psychological intervention, e.g. CBT, interpersonal therapy (IPT) or couples therapy.
For people with moderate or severe depression:
o Provide a combination of antidepressant medication and a high-intensity psychological intervention (CBT
or IPT).
o When an antidepressant is to be prescribed, it should normally be a SSRI in a generic form because
SSRIs are equally effective as other antidepressants and have a favourable risk-benefit ratio.
o If a person’s depression shows no improvement after two to four weeks with the first antidepressant, check
that the drug has been taken regularly and in the prescribed dose.
o If response is absent or minimal after three to four weeks of treatment with a therapeutic dose of an
antidepressant consider:
Increasing the dose in line with the reference dose range if there are no significant side effects, or
switching to another antidepressant if there are side effects or if the person prefers.
When switching to another antidepressant consider switching:
- Initially to a different SSRI or a better tolerated newer-generation antidepressant.
- Subsequently to an antidepressant of a different pharmacological class that may be less well
tolerated, e.g. venlafaxine, a tricyclic antidepressant (TCA), or a monoamine oxidase inhibitor
(MAOI).
If a person is informed about and prepared to tolerate the increased side effect burden, consider
augmenting an antidepressant with:
A mood stabiliser such as lithium.
An antipsychotic such as aripiprazole, olanzapine, quetiapine or risperidone.
Another antidepressant such as mianserin or mirtazapine.
Duration of treatment:
o Use antidepressants for at least six to nine months for first episode depression or two years for recurrent
depression.
o All patients should be informed about the withdrawal (discontinuation) effects of antidepressants.
Response to treatment:
o There is a 55-70% response rate with antidepressants for acute depression.
o If a person’s depression has not responded to either biological or psychological interventions, consider
combining antidepressants with cognitive behavioural therapy.
Electroconvulsive therapy (ECT) is supported in severe and treatment-resistant depression.
Key points that patients should know about antidepressants
Contrary to the common belief that antidepressants often take 2-4 weeks to start working, there is compelling
evidence that antidepressants at effective doses produce partial improvements within the first two weeks of
treatment (e.g. reduced motor retardation and irritability in addition to initial improvements in mood and sleep).
A single episode of depression should be treated for at least six to nine months after remission.
The risk of recurrence of depressive illness is high and increases with each episode.
Those who have had multiple episodes of depression may require treatment for many years.
60
