Leitlinien- Clearingbericht "Depression

Transcription

1 Schriftenreihe Band 12 Leitlinien- Clearingbericht "Depression Leitlinien-Clearingverfahren von Bundesärztekammer und Kassenärztlicher Bundesvereinigung in Kooperation mit Deutscher Krankenhausgesellschaft Spitzenverbänden der Krankenkassen und Gesetzlicher Rentenversicherung

2 ISBN ISSN by ÄZQ Aachener Straße Köln Verlag videel OHG, Niebüll Schmiedestr Niebüll Tel.: , Fax: [email protected] Gesamtherstellung: videel, Niebüll Geschützte Warennamen (Warenzeichen) werden nicht immer kenntlich gemacht. Aus dem Fehlen eines solchen Hinweises kann nicht geschlossen werden, dass es sich um einen freien Warennamen handelt. Alle Rechte, insbesondere das Recht zur Vervielfältigung und Verbreitung sowie der Übersetzung, vorbehalten. Kein Teil des Werkes darf in irgendeiner Form ohne schriftliche Genehmigung des Herausgebers oder des Verlages reproduziert werden. Der Herausgeber hat das Recht, Teile des Werkes oder das Gesamtwerk elektronisch zu publizieren. Bibliografische Information Der Deutschen Bibliothek Die Deutsche Bibliothek verzeichnet diese Publikation in der Deutschen Nationalbibliografie; detaillierte bibliografische Daten sind im Internet über abrufbar. Bibliographic information published by Die Deutsche Bibliothek Die Deutsche Bibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data are available in the Internet at

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51 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO3UlYDOHQ]GDWHQ $XVJHZlKOWZHJHQGHU'DUVWHOOXQJGHUZLFKWLJVWHQ3UlYDOHQ]GDWHQXQGLKUHUHPSLULVFKHQ %DVLV 5. How common is depression? Table 1.4 summarizes the Canadian epidemiologic studies showing similar prevalence rates of MDD. In the Stirling County Study (38), the same general Atlantic Canada population was surveyed at 3 points (1952, 1970, and 1992), an approach that has not been duplicated by any other study. Its prevalence results are similar, how ever, to those of the Edmonton Epidemiologic Study, which involved a random sample of adult residents of Edmonton, and the Ontario Mental Health Supplement (OMHS), which used a random sample of individuals aged 15 years or older residing in Ontario (39,40). A smallersample study using similar survey techniques in Quebec found a 3.4% 1-year prevalence and a 7.8% lifetime prevalence of depression (41). Cross-national studies suggest that the prevalence of depression is increasing in younger birth cohorts (42,43). The Stirling County Study, however, found a steady overall prevalence of current depression of 5% over a 40-year period. Women and younger people were at greater risk of depression in 1992 than in 1970, suggesting that the perceived historical change may be a matter of redistribution by sex and age. 6. Do depression rates vary by sex, age, or other demographic factors? Depression in women occurs at approximately twice the rate for men, according both to the major Canadian studies (38,40,44) and to international studies (1). There is less consistency among studies regarding prevalence related to age, but there do appear to be higher rates in young adults and lower rates in those over 64, most recently demonstrated in the National Population Health Survey (NPHS) (45). Many studies find depression more commonly in those with low income or unemployment and in those with unmarried or divorced status. Canadian data (46) also show parental psychopathology and a history of childhood abuse to be more common among individuals with depression. Differences in the rates of major depression are found across countries (Table 1.5), suggesting that cultural differences or variations in risk factors may play a role in the expression and development of depression (1,42). The core symptoms, however, remain similar in many countries (47) and across North America (1). Risk of social disability after controlling for physical disease/ disability factors. Work productivity is also markedly affected. Ontario residents with a history of depression in the past year were nearly 3 times as likely as were control subjects to have sick days in the preceding month, while a similar US survey found that workers with depression had 1.5 to 3.2 more short-term work-disability days in a 30-day period than did other workers (40,50). In the latter study, the salary-equivalent productivity loss (which averaged USD182 to USD395) was nearly as large as the estimated cost of depression treatment. Another study found that individuals with depression had 5 times as many disability days as did unaffected individuals (51).

52 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO3UlYDOHQ]XQG6\PSWRPHUNHQQXQJLQYHUVFKLHGHQHQ$OWHUVJUXSSHQ $XVJHZlKOWZHJHQGHUSUD[LVQDK]XVDPPHQJHIDVVWHQ'DUVWHOOXQJYRQ6\PSWRPVFKZHU SXQNWHQGHU3UlYDOHQ]DQJDEHQGLHEHLGHQlOWHUHQ0HQVFKHQQDFK,QDQVSUXFKQDKPH 6WLFKSUREHQGLIIHUHQ]LHUWVLQGXQGGHVhEHUEOLFNHV EHUGLHDOWHUVEH]RJHQH3UlYDOHQ]YRQ 6XL]LGHQ Table 6.1 Summary of age-related differences in depression and suicide across the lifespan Age group Clinical presentation and assessment Epidemiology Suicide rates per a Age (years) Male subjects Female subjects Children and Adolescents Elderly May have protracted episodes; illness pattern of remission and relapse, and significant impairments in social, interpersonal, vocational, or academic functioning. Cognitive distortions and decreased selfesteem following remission may predict future episodes Core symptoms of severe depression are the same as for younger adults, but there is more difficulty differentiating symptoms because of medical comorbidity and more likelihood that seniors with depression will present with cognitive symptoms. More willing to self-identify physical rather than mental symptoms and less likely to participate in formal mental health programs. The oldest patients show the most variance from younger adults, and young-old may present more similarly than differently from middle-aged patients. The prevalence of major depressive disorder (MDD) is relatively low before puberty, but rates reach adult levels by late adolescence. Female male ratio equal in childhood but same as adult female:male ratio (2:1) in adolescence. Rates of depressive disorder decreased in community samples but increased in institutional or hospital samples. Subsyndromal depressions likely to be more frequent

53 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO6R]LDOHXQG6R]LDOPHGL]LQLVFKH%HGHXWXQJ $XVJHZlKOWZHJHQGHU'DUVWHOOXQJ]HQWUDOHU$VSHNWHGHUVR]LDOHQXQG JHVXQGKHLWV NRQRPLVFKHQ%HGHXWXQJGHSUHVVLYHU6W UXQJHQXQGGHU9HUNQ SIXQJPLW HPSLULVFKHU(YLGHQ] 7. How disabling is depression? Depressive symptoms substantially interfere with daily functioning, and MDD is a leading cause of disability in developed countries (48). In the US National Comorbidity Survey, 18% of patients with minor depression, 29% of patients with 5 to 6 symptoms of MDD, and 52% of patients with 7 to 9 symptoms of MDD had major problems with daily functioning (3) Work productivity is also markedly affected. Ontario residents with a history of depression in the past year were nearly 3 times as likely as were control subjects to have sick days in the preceding month, while a similar US survey found that workers with depression had 1.5 to 3.2 more short-term work-disability days in a 30-day period than did other workers (40,50) How does depression affect the use of Health services? Both major depression and dysthymia are associated with an increased use of general medical services or emergency services for emotional problems as well as with more time lost at work (56,57). Even 2 or more depressive symptoms over a life time are associated with increased rates of social morbidity and service use. In fact, from a population, societal, or service burden perspective, individuals with depressive symptoms use more medical services and attempt suicide more frequently than do individuals with cases de fined as MDD by DSM- IV (56). From an other perspective, studies of high utilizers of general health services demonstrate high rates of untreated depression (58). Treating these individuals improves health outcomes and, in time, may lessen service use (59).. 10 What does depression cost individuals and society Major depression is more prevalent than other major public health problems and imposes significant costs on society. The WHO Global Burden of Disease Study quantified illness-related morbidity and mortality into a common unit, the disability-adjusted life year (DALY). When DALYs were calculated for 107 diseases and disorders world wide, unipolar major depression was the fourth leading specific cause of global DALYs (69) and predicted to be second by the year 2020 (4). In the US in 1990, the total annual cost of depression was estimated to be USD 44 billion: direct costs were USD12 billion, mortality costs were USD 8 billion, and absenteeism/productivity costs were USD 24 billion (70). This figure included cases of bipolar depression and dysthymia but did not include out-of-pocket family expenses, costs of minor depression, or excessive hospitalization or diagnostic tests. Similar calculations for Ontario in 1990 found the total annual cost of depressive disorders to be CAD million, of which 58% was attributed to in direct costs and 44% to morbidity-related costs (71). Such figures, however, underestimate the true cost of depression because several key categories of cost are not included, such as impact on over all general medical service use and family burden costs (72)...

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55 /HLWOLQLHQEHULFKW'HSUHVVLRQ ¾*UXSSHQYRQ5LVLNRIDNWRUHQ]XGHQHQHPSLULVFKH(YLGHQ]YRUOLHJWXQGGLHGHVKDOELQGHU /HLWOLQLHQGDUVWHOOXQJHQWKDOWHQVHLQVROOWHQVLQG ELRORJLVFKHHLQVFKOLH OLFKJHQHWLVFKHUXQGVRPDWLVFKHU5LVLNRIDNWRUHQ SV\FKRORJLVFKH5LVLNRIDNWRUHQHLQVFKOLH OLFKGHU(LQIO VVHGHVVR]LDOHQ8PIHOGV XQGGHUHQ9HUDUEHLWXQJ]%7RGHVIlOOHXQGIU KH9HUOXVWH VR]LRGHPRJUDSKLVFKH)DNWRUHQ]%QLHGULJHV(LQNRPPHQ YRUDXVJHKHQGHN USHUOLFKH=XVWlQGHE]Z(UNUDQNXQJHQ]%0HQRSDXVH SV\FKLVFKH6\QGURPHLP9RUIHOGXQGYRUDXVJHKHQGHSV\FKLVFKH(UNUDQNXQJHQ ]%$QJVWVW UXQJHQ ¾,QGHU/HLWOLQLHVROOWHQGLH'DWHQEDVLVUHWURVSHNWLYSURVSHNWLYNRQWUROOLHUWXQGGLH SURJQRVWLVFKH3RZHU9RUKHUVDJHEHGHXWXQJI UGLHMHZHLOLJHQ)DNWRUHQJHQDQQW ZHUGHQ ¾:HJHQGHUEHVRQGHUHQ%HGHXWXQJGHU$GROHV]HQ]I UGDVVSlWHUH'HSUHVVLRQVULVLNR VROOWHHLQ9HUZHLVDXIVSH]LHOOH/HLWOLQLHQ]XGHSUHVVLYHQ6\QGURPHQEHL.LQGHUQXQG -XJHQGOLFKHQHUIROJHQ ¾1HEHQGLHVHU]XVDPPHQIDVVHQGHQ'DUVWHOOXQJYRQHYLGHQ]EDVLHUWHQ5LVLNRIDNWRUHQVROOWH HLQHhEHUVLFKWYHUGHXWOLFKHQZHOFKH,QGLNDWLRQHQEHLHLQHU.RPELQDWLRQHUNDQQWHU 5LVLNRIDNWRUHQEHVWHKHQ]%6FUHHQLQJIUDJHQ]XU'HSUHVVLRQI UDOOH3DWLHQWHQEHL GHQHQ$QJVWV\QGURPHHWFEHUHLWVGLDJQRVWL]LHUWEHKDQGHOWZHUGHQ ¾hEHUHLQH]XVDPPHQIDVVHQGH'DUVWHOOXQJ]XbWLRSDWKRJHQHVHXQG5LVLNRIDNWRUHQKLQDXV VROOWHEHLGHUVSlWHUHQ'DUVWHOOXQJYRQ7KHUDSLHRSWLRQHQDXIGLH]XJUXQGHOLHJHQGHQ lwlrsdwkrjhqhwlvfkhq0rghoohe]zdxi3ureohphyhuvfklhghqhulwlrsdwkrjhqhwlvfkhu.rq]hswhklqjhzlhvhqzhughq'dvjlowehvrqghuvgdqqzhqqvlfkehlehvwlppwhq 6XEW\SHQGHSUHVVLYHU6W UXQJHQ]%'\VWK\PLHQUH]LGLYLHUHQGH'HSUHVVLRQHQDXVGHU $QQDKPHEHVWLPPWHU0RGHOOH.RQVHTXHQ]HQI UGLHZHLWHUH'LDJQRVWLNXQG7KHUDSLH HUJHEHQ %HLVSLHObWLRSDWKRJHQHVH $XVJHZlKOWZHLOKLHUHLQH]LHOJUXSSHQJHUHFKWH+DXVlU]WH]XU$QZHQGXQJEHL.ODVVLILNDWLRQXQG'LDJQRVWLNI KUHQGHZHJZHLVHQGH'DUVWHOOXQJHUIROJW1HEHQGHQ +LQZHLVHQ]X3UlYDOHQ]LQGHU3UD[LVZLUGDXIGLH]XP=HLWSXQNWGHU/HLWOLQLHQHUVWHOOXQJ XQJHNOlUWHQ3XQNWH]XUbWLRORJLHKLQJHZLHVHQ Vorbemerkungen zur Pathologie und Pathophysiologie Die Depression ist eine häufig vorkommende Erkrankung, deren gesamt-wirtschaftliche Kosten denen der koronaren Herzkrankheit vergleichbar sind. Sie ist gekennzeichnet durch eine hohe Rezidivneigung und eine hohe Mortalität. Die Prävalenz in der Allgemeinpraxis beträgt %. Wie bei anderen psychischen Krankheiten und Störungen ist auch beim depressiven Syndrom von einer multifaktoriellen Ätiopathogenese auszugehen, bei der im Einzelfall unterschiedliche Ursachen im Vordergrund stehen. Es wird angenommen, daß dem seelischen Erleben ein somatisches Korrelat (z. B. Störung im Neurotransmitterstoffwechsel) entspricht, jedoch ist dieses nicht gesichert oder verstanden. Das Leiden tritt familiär gehäuft auf, ohne daß der genaue Erbgang bekannt wäre. Das Syndrom kann außerordentlich leidvoll für alle Beteiligten sein und endet oft im Suizid. Etwa jeder zehnte wird einmal in seinem Leben an einer behandlungsbedürftigen Episode leiden. Die Krankheit ist leibnah und wird häufig als Störung in der Vitalsphäre am deutlichsten erlebt. Klassifikation Der traditionellen Einteilung der depressiven Erkrankungen liegt eine umstrittene Ätiologie zugrunde: als Ursachen wurden psychogene Faktoren wie z. B. belastende Lebensereignisse oder eine neurotische Entwicklung (depressive Reaktion, neurotische Depression), anlagebedingte, z. T. genetisch fixierte, im einzelnen unbekannte Faktoren (endogene Depression) oder körperliche Erkrankungen (organisatorische Depression) unterschieden. Da die Ätiopathogenese multifaktoriell ist, verzichtet die neue Klassifikation nach ICD-10 (Tabelle 1) weitgehend auf Vermutungen zur Ätiologie und benennt rein beschreibend das...

56 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO,GHQWLIL]LHUWHXQGSV\FKRORJLVFKH5LVLNRIDNWRUHQ $XVJHZlKOWZHJHQGHU EHUVLFKWOLFKHQ$XIOLVWXQJDOOJHPHLQDQHUNDQQWHU5LVLNRIDNWRUHQXQWHU (UJlQ]XQJHLQHU]XVDPPHQIDVVHQGHQ'DUVWHOOXQJHYLGHQ]EDVLHUWHUSV\FKRORJLVFKHU 5LVLNRIDNWRUHQZREHLKLHUQLFKWQXU5LVLNRVRQGHUQDXFK6FKXW]IDNWRUHQHUZlKQWZHUGHQ Aetiology and risk factors The concept of depressive disorders can be traced back to the earliest periods of recorded history. Hippocrates wrote of melancholia and the literal translation of Dysthymic Disorder is ill humoured. However, it was not until 1972 that the term Major Depressive Disorder was first introduced as a category in the Feighner Diagnostic Criteria. This concept was included in the DSM-III which brought together all the affective conditions into a classification based on symptoms rather than underlying personality. Kendler et al (1993) have retrospectively calculated the risks contributing to a particular episode of Major Depressive Disorder in a large group of female twins and found that there is a complex interaction of the following factors: Stressful life events and difficulties in the last three months, eg financial difficulties History of traumatic events, including abuse (physical, sexual and emotional), divorce and social isolation Exposure to dysfunctional parenting Premature parental loss Previous history of depression Genetic factors Neuroticism Poor social support. Brown and Moran (1994) and Brown et al (1994) found that childhood adversity (including parental indifference, family violence and sexual abuse) and current interpersonal difficulties were predictors of a chronic course of depression among working class mothers living in inner London and clients treated for depression at two London hospitals. Substance abuse has also been observed as a factor in predicting the chronicity of some depressive disorders, especially amongst men. The Otago Women s Health Survey found the following factors to be associated with the onset of psychiatric illness (anxiety and depression): being separated/ divorced, coming from a large family, having poor social networks, living alone, having few social responsibilities, financial difficulties and poor physical health. When assessed at the 30 month follow up, they discovered that middle aged women (45-64) were less likely to have recovered than either their younger or older counterparts. They considered that a factor contributing to this is the social role adjustment that women have to make once their child rearing responsibilities have ended (Romans et al, 1993, 1993a). Similar risk factors are likely to be operative in the aetiology of Dysthymic Disorder. The diathesis-stress model suggests that mental illness is a product of the interaction between a predisposition towards an illness/disorder and stressful events (Davison and Neale, 1990). A person may be predisposed genetically and psychologically (ie hold negative beliefs and attitudes about themselves and the world) towards developing a Major Depressive Disorder. If sufficient stressors occur (the relative impact of these being determined by the person s coping skills), the disorder develops. These stressors may include physiological stressors (eg experiencing a closed head injury) and psychological stressors (eg experiencing a traumatic event). There are also protective factors that will decrease the likelihood of developing a depressive episode: Perceived parental warmth Social support Coping skills and personality style

57 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO%LRORJLVFKH5LVLNRIDNWRUHQ $XVJHZlKOWZHJHQGHV$QVSUHFKHQVJHQHWLVFKHU)DNWRUHQXQGGHU'LIIHUHQ]LHUXQJ]ZLVFKHQ YHUVFKLHGHQHQGHSUHVVLYHQ6W UXQJHQ Guideline: A history of mood disorders in first-degree relatives increases the probability of a patient s developing a mood disorder. (Strength of Evidence = A.) First-degree relatives of bipolar disorder patients are at substantially higher risk for developing either a recurrent major depressive disorder (roughly 12 percent) or bipolar disorder (roughly 12 percent). Strong scientific evidence points to a genetic vulnerability to bipolar disorder. For those with more recurrent forms of major depressive disorder, genetic factors also appear to play a significant role. For those with less recurrent forms of major depressive disorder, the role of genetic factors is unclear. It is known, however, that patients who develop major depressive disorder before age 20 have a greater familial morbidity for depression. %HLVSLHO1HXURELRORJLVFKHV5LVLNR //'*331>6@ $XVJHZlKOWZHJHQGHUYRUVLFKWLJHQ)RUPXOLHUXQJHQGLHGDUDXIYHUZHLVHQGDVVLQGLHVHP %HUHLFKQRFK)RUVFKXQJVEHGDUIEHVWHKW Als neurobiologische ätiopathologische Grundlagen werden Störungen in der Reagibilität des stressregulierenden neuroendokrinologischen Systems (Limbisches System/ Hypothalmus/ Hypophyse/ Nebennierenrinde) vermutet, die sowohl Ursache als auch Wirkung von Störungen in der adaptiven Kapazität von limbischen Neurotransmittersystemen (Noradrenalin, Serotonoin, Dopamin, Acetylcholin) sein könnten. Insbesondere bei bipolaren Störungen wurden in letzter Zeit ursächlich auch Funktionsanomalien diskutiert, die möglicherweise der Hauptangriffspunkt im Wirkungsmechanismus von stimmungsstabilisierenden Medikamenten (Lithium, Valproat, Carbamzepin) sind. %HLVSLHO. USHUOLFKH=XVWlQGHE]Z(UNUDQNXQJHQDOV5LVLNRIDNWRU //$NGb>67DEHOOH@ $XVJHZlKOWZHJHQGHUJHQDQQWHQXQWHUVFKLHGOLFKHQ$UWHQVROFKHU5LVLNRIDNWRUHQ Biologisch Erschöpfung nach chronischer psychophysischer Anspannung, Folter Schwere körperliche Erkrankung Wochenbett Alkohol, vor allem bei längerem Gebrauch in höherer Dosierung, im Entzug oder danach Pharmakogen, z. B. Betarezeptorenblocker, Cortison (auch Manien), Gyrasehemmer, Reserpin Bei Absetzen von Benzodiazepinen, bei Opiatabhängigkeit und Polytoxikomanie, auch im Entzug Hypophysenvorderlappen-Insuffizienz, Hypothyreose

58 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO$XVO VHUYRQ'HSUHVVLRQ $XVJHZlKOWZHJHQGHU8QWHUVFKHLGXQJ]ZLVFKHQÄZDKUVFKHLQOLFKHP³XQGÄP JOLFKHP³ *HIDKUHQSRWHQ]LDOGHUDQJHI KUWHQ0HGLNDPHQWH Table 7.1 Medications with potential to induce depression Medications with a probable association: Anabolic steroids Interferons... Medications with a possible association: Cardiovascular Captopril (and other angiotensin-converting-enzyme [ACE] inhibitors)... Other Various anticonvulsants... %HLVSLHOH]XU'DUVWHOOXQJZHLWHUHU5LVLNRIDNWRUHQVLHKHDXFK!%HLVSLHO6R]LRGHPRJUDSKLVFKH3UlYDOHQ]GDWHQ!%HLVSLHO3UlYDOHQ]XQG6\PSWRPHUNHQQXQJLQYHUVFKLHGHQHQ$OWHUVJUXSSHQ %HLVSLHO,QGLNDWLRQHQEHLHUNDQQWHQ5LVLNRIDNWRUHQ $+&35>9RO6@ $XVJHZlKOWZHJHQGHVH[SOL]LWHQ+LQZHLVHVDXI0D QDKPHQGLHEHLEHVWLPPWHQ 5LVLNRIDNWRUHQ]XHUJUHLIHQVLQG Given that follow-up studies of those with panic or other anxiety disorders reveal that many will subsequently develop major depressive disorder and that they often have had a prior major depressive disorder or have a family history of major depressive disorder, the depression is the appropriate main target of treatment in many cases. Sometimes, however, only a treatment trial and observation will answer this complex diagnostic question. Whichever disorder is primary, the data are clear that the combination of panic and major depressive disorders results in a more severe disorder with greater impairment than does either disorder alone. For example, depressed patients with associated panic attacks have a more severe depressive illness and are less likely to recover during a 2-year follow up than are those without panic attacks (Coryell; endicott; Andersan et all., 1988). The lifetime suicide attempt rate for persons with both panic and major depressive disorders is more than twice that of those with panic disorder, but without major depressive disorder (19.5 versus 7.0 per 100) (Johnson, Weisman and Klerman 1990). In two separate studies, panic disorder and primary major depressive disorder were each associated with high suicide rates (Coryell; Noyes; and Clancy 1982, 1983). These data strongly suggest the importance of inquiring about, and even expecting to find, a concurrent mood disorder (especially major depressive disorder) in patients with anxiety complaints. If an individual presents with both conditions and if they are equally impairing, the practitioner should consider treatment with medications for which efficacy has been demonstrated for both conditions. These include MAOIs, SSRIs, TCAs, or in selected cases alprazolam.

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60 /HLWOLQLHQEHULFKW'HSUHVVLRQ ¾:HQQVLFKDXVGHP9RUOLHJHQEHVWLPPWHU3URJQRVHNULWHULHQ(PSIHKOXQJHQI UGDV SUDNWLVFKH9RUJHKHQDEOHLWHQODVVHQVROOWHQGLHVHLQGHQ(PSIHKOXQJHQLQVEHVRQGHUH GDQQZHQQDXFKGLH(PSIHKOXQJHQHPSLULVFKEHJU QGHWZHUGHQN QQHQEHU FNVLFKWLJW ZHUGHQ %HLVSLHO)DNWRUHQGLHGLH5 FNIDOOZDKUVFKHLQOLFKNHLWHUK KHQ $XVJHZlKOWZHJHQGHU1RWZHQGLJNHLW]XQlFKVWHLQHQhEHUEOLFN]XJHEHQ EHU)DNWRUHQ GHUHQ(LQIOXVVDXIGHQZHLWHUHQ(UNUDQNXQJVYHUODXIJHVLFKHUWLVW...Factors increasing the risk of future recurrence include: A strong family history of mood disorders A history of recurrence within one year after discontinuation of a previously efficacious medication One or more suicide attempts Onset of the first episode before age 20 Two or more episodes of major depression in the past two years Concurrent dysthymia %HLVSLHO3URJQRVHQDFK6\PSWRPDWLNXQG(UNUDQNXQJVYHUODXI //&3$>6@ $XVJHZlKOWZHJHQGHU(LQEH]LHKXQJGHU(YLGHQ]EDVLVXQGGHU'LIIHUHQ]LHUXQJ]ZLVFKHQ YHUVFKLHGHQHQ6XEJUXSSHQGHSUHVVLYHU6W UXQJHQ 3. What factors predict recovery, and how should recovery be defined? In general, the longer a patient is symptomatic, the lower the likelihood of recovery. One longitudinal study found that more than 50% of patients with MDD recovered within 6 months, but thereafter, recovery rates sharply decreased with time (15). Compared with patients with MDD alone, patients with double depression (dysthymic disorder with concurrent MDD) are more likely to have continued depressive symptoms after 2 years of follow- up (16). In a 12-month follow-up study of in patients with depression, longer hospital stay, younger age of onset, poorer family functioning, more than 2 prior hospitalizations, and the presence of a comorbid illness were significantly associated with a lower recovery rate (17). Other factors predicting a longer time to recovery include longer duration and increased severity of the index episode, prior history of a nonmood psychiatric disorder, a lower family income and being married (18), and poorer family functioning (19). On the other hand, the cumulative probability of recovery can be up to 88% after 5 years of treatment (15), and recoveries have occurred even after 15 years of illness (11). Factors associated with recovery from chronic MDD (> 2 years) include a relatively high maximum level of functioning in the 5 years preceding intake, less severe illness at intake, lack of psychotic features, and good friendship patterns in adolescence (20). Elsewhere, psychosocial and family factors were predictive of a longterm (6-year) course of MDD (21)....

61 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO.RPRUELGLWlWHQXQG)ROJHHUNUDQNXQJHQ $XVJHZlKOWZHJHQGHU(UZlKQXQJGHUZLFKWLJVWHQYHUODXIVEHHLQIOXVVHQGHQ.RPRUELGLWlWHQ XQG*UXSSHQYRQ)ROJHHUNUDQNXQJHQ 4. What other disorders commonly co-occur with depression? Depressive disorders are frequently comorbid with other psychiatric and medical conditions (see Section VII). High rates of comorbid anxiety disorders and substance abuse/dependence are reported in both clinic and community samples (1,29,30). Psychiatric comorbidity has been associated with both increased disease severity and a poorer prognosis (31). In addition, personality disorders have been diagnosed in 41% to 81% of patients with depression in clinic samples, and MDD occurs in up to 35% of patients with certain personality disorders (32,33). A multisite study of chronic major and double depression found that the most frequent personality disorders comorbid with chronic depression were avoidant (25%), obsessive - compulsive (18%), and selfdefeating (16%) (34). The presence of borderline personality disorder (BPD) or dependent personality traits predicts MDD relapse (35). Major depression is also frequently seen in patients with a wide variety of chronic physical illnesses ranging from migraine headaches to cancer to post stroke and post myocardial infarction (36,37). In general, patients with comorbid medical illnesses are more likely to present with chronic conditions, and have a higher risk of suicide attempts, than are patients with a single medical or psychiatric diagnosis (3). %HLVSLHO$QVSUHFKHQDXIELVKHULJH7KHUDSLHQ $+&35>'HSUHVVLRQLQ3ULPDU\&DUH9RO6I@ $XVJHZlKOWZHJHQGHU]XVDPPHQIDVVHQGHQ$XVVDJH]XUSURJQRVWLVFKHQSKDVHQDEKlQJLJHQ %HGHXWXQJHLQHVQLFKWYROOVWlQGLJHQ$QVSUHFKHQVDXI7KHUDSLHQ It is reasonably well established that patients who have only a partial response to acute treatment will have more symptoms during continuation treatment. Furthermore, those with poor symptom control during continuation treatment have a higher chance of earlier relapse, as well as recurrence once treatment is discontinued (Prien and Kupfer, 1986). Figure 5

62 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO'HSUHVVLRQDOV.RPSOLNDWLRQVIDNWRU $XVJHZlKOWZHJHQGHU%HOHJHGDVV'HSUHVVLRQGLH0RUWDOLWlWVWHLJHUWXQG]XXQJ QVWLJHQ 9HUOlXIHQDXFKEHLDQGHUHQ(UNUDQNXQJHQEHLWUlJW 9. What contributes to elevated death rates in persons with depression? Persons with depression have increased mortality rates both through direct (suicide) and through indirect mechanisms. In a study of 4000 patients with depressive disorders, the standardized mortality rate doubled for all causes of death but was increased 26-fold for suicide (60). Similarly, in a small clinical sample overall mortality risk doubled, with a 7-fold increased mortality rate for women under age of 40 years at index admission (11).... The life time prevalence of suicide is estimated at 2.2% for a mixed group of inpatients/outpatients with depression, compared with 0.5% for nonaffectively ill patients, and up to 8.6% for patients hospitalized for suicidality (61)... For example, patients with coronary artery disease have an increased risk of subsequent death by cardiac or other causes if they are depressed at the time of hospitalization, and this increased risk is sustained for at least 10 years (66). Depression is similarly associated with more than a 3-fold increased risk of death during the first year after a diagnosis of unstable angina and more than a 4-fold increased risk of death during the first 3 months after acute myocardial infarction (37,67). The increased risk of death from cardiovascular disease may be due both to direct effects (such as decreased heart rate variability, increased platelet aggregation, and altered autonomic tone) and to indirect effects (such as poor selfcare, in creased smoking, and alcohol consumption) and appears to affect men more than women (65,68). :HLWHUHV%HLVSLHO]XU'DUVWHOOXQJYRQ3URJQRVHIDNWRUHQVLHKHDXFK!%HLVSLHO3UlYDOHQ]XQG6\PSWRPHUNHQQXQJLQYHUVFKLHGHQHQ$OWHUVJUXSSHQ

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66 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO'LDJQRVWLNGHU6XEV\QGURPV6XL]LGDOLWlW $XVJHZlKOWZHJHQGHU3UD[LVQlKHXQGGHVVWUXNWXULHUWHQ9RUJHKHQV MANAGEMENT OF MAJOR DEPRESSIVE DISORDER IN ADULTS Appendix 3. Suicidality The potential threat of self-harm and violence and the assessment of the potentially violent patient have been... Evaluation of the Potentially Suicidal Patient The evaluation itself consists of three main parts: 1. Eliciting suicidal ideation or intent 2. Gathering data on risk factors for completed suicide 3. Weighing items one and two to assess safety. 1. Eliciting Suicidal Ideation or Intent Ideally, eliciting suicidal ideation or intent involves a free and honest exchange of information between patient and clinician. Unfortunately, this is not always so. Familiarity with the existing epidemiological and demographic data concerning suicide (see below) is useful in generating an index of suspicion. From there, direct questioning regarding suicidal ideation/intent may be initiated. There are no data demonstrating an increased rate of suicide attempts or completions following questioning about suicide. Avoid rushing this part of the history or putting it off. Despite the lack of reliable measures of suicide risk among individuals, a basic assessment should (Goldberg, 1987): a. Determine presence/absence of delirium, psychosis, or depression b. Elicit patient s statements about his/her suicidality c. Elicit patient s own ideas concerning what would help attenuate or eliminate suicidal ideation/intent d. Attempt to gather collateral data from a third party in order to confirm the patient s story e. A suggested sequence of suicide questions to ask is: Are you discouraged about your medical condition (or social situation, etc.)? Are there times when you think about your situation and feel like crying? During those times, what sorts of thoughts go through your head? Have you ever felt that if the situation did not change, it would not be worth living? Have you reached a point that you ve devised a specific plan to end your life? Do you have the necessary items for completion of that plan readily available? f. Formulate acute and chronic management plan. Encourage active patient participation in negotiating a plan for follow-up. What epidemiological risk factors are present (may have to inquire about each one individually)? What other psychiatric conditions are present (besides the ones mentioned above)? What is the level of psychological defense functioning? Has there been a will made recently? Is there talk of plans for the future? What is the makeup and condition of the patient s social support system? How can they be contacted? Is there active suicidal ideation? How strong is (your) intent to do this? Can you resist the impulse to do this? Do you tend to be impulsive? Have you ever rehearsed how you would kill yourself? Have any family members or people close to you ever killed themselves? 2. Risk Factors for Completed Suicide... :HLWHUHV%HLVSLHODOV+LQZHLV]XU'LDJQRVWLNGHU6XL]LGDOLWlWVLHKHDXFK!%HLVSLHO3UlYDOHQ]XQG6\PSWRPHUNHQQXQJLQYHUVFKLHGHQHQ$OWHUVJUXSSHQ

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68 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO0HKUD[LDOH'LDJQRVWLN $XVJHZlKOWZHJHQGHU EHUVLFKWOLFKHQ=XVDPPHQVWHOOXQJGHU'LDJQRVHDFKVHQHLQVFKOLH OLFK GHV+LQZHLVHVDXIHLQ,QVWUXPHQW PXOWLD[LDOHYDOXDWLRQUHSRUWIRUP GDVVGLH$QZHQGXQJ GLHVHU9RUJHKHQVZHLVHXQWHUVW W]W 2. Evaluate Psychiatric Symptoms and Co-Morbidities Multiaxial Assessment This system involves an assessment on each of five axes. Each axis refers to a different domain of information that may help the clinician assess the patient, plan treatment and predict outcome. Axis I: Clinical Disorders, Other Conditions That May Be a Focus of Clinical Attention This axis is for listing all diagnoses of mental illness and psychiatric conditions, except for the personality disorders and mental retardation. Axis II: Personality Disorders, Mental Retardation This axis is for reporting personality disorders, mental retardation, and prominent maladaptive personality features and defense mechanisms. Axis III: General Medical Conditions *If mood disorder is due to a general medical condition then it is out of the guideline. Current general medical conditions which are or may be potentially relevant to the listed Axis I and II disorders are reported in this axis. There are no definitive studies which support recommendations for or against routine laboratory or medical screening. Axis IV: Psychosocial and Environmental Problems Psychosocial and environmental problems which may affect the diagnosis, treatment and prognosis of Axes I and II are noted here. When using the Multiaxial Evaluation Report Form, the clinician should identify the relevant categories of psychosocial and environmental problems and indicate the specific factors involved. If a recording form with a checklist of problem categories is not used, the clinician may simply list the specific problems on Axis IV. Categories of problems to be considered include: ¾problems with primary support group ¾problems related to the social environment ¾educational problems ¾occupational problems ¾housing problems ¾economic problems ¾problems with access to health care services ¾problems related to interaction with the legal system/crime ¾other psychosocial and environmental problems Axis V: Global Assessment of Functioning Axis V is for reporting the clinicians judgement of the individuals overall level of functioning. This information is useful in rating severity, planning treatment, and measuring its impact, as well as in predicting outcome. See Appendix A for Global Assessment Form scale. Evidence supporting this conclusion is of classes: C, R

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70 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO.DWHJRULDOH'LDJQRVWLN $XVJHZlKOWZHJHQGHUHLQIDFKHQSUD[LVRULHQWLHUWHQ(LQRUGQXQJLQGLH.DWHJRULHXQGGHU +LQZHLVHDXIZLFKWLJHGLIIHUHQ]LDOGLDJQRVWLVFK]XEHU FNVLFKWLJHQGHhEHUOHJXQJHQ Depression F32# Presenting complaints The patient may present initially with one or more physical symptoms, such as pain or tiredness all the time. Further enquiry will reveal low mood or loss of interest. Irritability is sometimes the presenting problem. A wide range of presenting complaints may accompany or conceal depression. These include anxiety or insomnia, worries about social problems such as financial or marital difficulties, increased drug or alcohol use, or (in a new mother) constant worries about her baby or fear of harming the baby. Some groups are at higher risk (eg those who have recently given birth or had a stroke, and those with physical disorders, eg Parkinson s disease or multiple sclerosis). Diagnostic features Low or sad mood Loss of interest or pleasure At least four of the following associated symptoms are present: disturbed sleep poor concentration disturbed appetite suicidal thoughts or acts guilt or low self-worth loss of self confidence pessimism or hopelessness fatigue or loss of energy about the future agitation or slowing of decreased libido movement or speech diurnal mood variation Symptoms of anxiety or nervousness are also frequently present. Differential diagnosis Acute psychotic disorder F23 (if hallucinations [eg hearing voices] or delusions [eg strange or unusual beliefs] are present). Bipolar disorder F31 (if patient has a history of manic episodes [eg excitement, rapid speech, elevated mood]). Alcohol misuse F10 or Drug use disorder F11# (if heavy alcohol or drug use is present). Chronic mixed anxiety and depression F41.2. Some medications may produce symptoms of depression (eg beta-blockers, other antihypertensives, H2 blockers, oral contraceptives, corticosteroids). Unexplained somatic complaints, anxiety, alcohol or drug disorders may co-exist with depression.

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72 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO.RPRUELGLWlWHQ 8QLYHUVLW\RI0LFKLJDQ+HDOWK6\VWHP'HSUHVVLRQ*XLGHOLQH67DE $XIJHI KUWZHJHQ$QJDEHQ]XU+lXILJNHLW,GHQWLILNDWLRQVKLOIHQXQGGLIIHUHQ]LDOWKHUD SHXWLVFKHU(UZlJXQJHQ Table 7. Prevalence and Treatment of Co-Morbid Depression Diagnosing Co- Morbid Conditions Co-Morbid Epidemiology Diagnosing Co-Morbid Conditions Special Rx Considerations Depression Depression accompanied by Alcohol Abuse Depression accompanied by Panic, Generalized Anxiety Disorder or Phobias Depression accompanied by Obsessive Compulsive Disorder Depression accompanied by Eating Disorders ¾ Approximately 30% of patients with MDD in primary care or the community will have a history of alcoholism or substance abuse. ¾ 16% of patients with MDD will have an alcohol disorder. ¾ 10-30% of alcoholics will have concurrent depression. ¾ 45% of patients with MDD have significant anxiety symptoms ¾ 15-30% of patients with MDD have a concurrent panic disorder ¾ Patients with panic/or anxiety disorders have lifetime rates of MDD of approximately 40-60% ¾ Phobias may be the most common comorbid condition with MDD. ¾ 10% of patients with MDD have a lifetime history of OCD ¾ 10-30% of patients with OCD will have MDD Perhaps as much as 5-6% of young women with MDD may have an eating disorder 30-50% of patients with eating disorders have concurrent MDD 50-75% of patients with eating disorders have a lifetime history of MDD Consider asking the CAGE questions: C Have you ever felt that you should cut down on your drinking? A Have people annoyed you by criticizing your drinking? G Have you ever felt bad or guilty about your drinking? E Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? If the patient answers yes to two or more of these questions, the provider should complete a thorough assessment or refer. Consider asking: Are you troubled by repeated, unexpected "attacks" where you suddenly feel very afraid or uncomfortable, for no apparent reason? During these attacks, do you experience? pounding heart; sweating; dizziness; trembling; feelings of unreality; shortness of breath or choking; fear of going crazy or dying; chest pain; numbness or tingling; chills or hot flashes? Do you fear situations where getting help or escaping might be difficult, such being in a crowd or on a bridge? Is it difficult for you to travel without a companion? For at least a month following an attack, do you: have persistent concerns about having another attack; worry that the attacks may have serious consequences, or change your behavior to avoid another attack? Consider asking: ¾ Do you have unwanted ideas, images, or impulses that keep recurring? ¾ Are there things you must do repeatedly or thoughts you must ¾ think repeatedly in order to feel comfortable? ¾ Do you worry excessively about dirt, germs, or chemicals; wash excessively; or have to check things over & over again? If patients have a significant weight loss, are dieting when not "over" weight, have frequent weight fluctuations, or are hamenorrheic consider asking: Are you afraid of becoming fat? Do you consider yourself fat? Do you have a strict diet or do you fast frequently? Do you have eating binges?; exercise a great deal?; make yourself vomit or use laxatives, water pills, or enemas? ¾ If there is concurrent alcohol abuse and depression, address the alcohol use first and attempt to achieve a period of sobriety. If depression is still present after several weeks of sobriety, then treat the depression. Many patients will have remission in depressive symptoms with abstinence [C*]. ¾ If unable to achieve several weeks of sobriety, patients with concurrent depression and alcohol abuse, may be treated with an SSRI [A*]. ¾ There are higher suicide rates among depressed patients with concurrent alcohol abuse. Be vigilant in assessment of suicidal risk [C* ]. ¾ If patients present with significant anxiety symptoms, look for MDD. ¾ MDD accompanied by anxiety disorders has a relatively poorer prognosis than MDD alone. There is a longer median time to recovery and greater morbidity [A*, C*]. ¾ Patients with MDD and panic disorder or generalized anxiety disorder (GAD) benefit from antidepressants; however, ¾ antidepressants need to be started at lower doses and increased more slowly in these individuals [C*]. ¾ SRIs and TCAs are effective in panic disorder. Bupropion is less effective [B*]. ¾ Patients with MDD and panic or phobia or avoidance may benefit from referral for cognitive behavioral therapy [A*]. ¾ Patients with depression and OCD should be treated with a SRI [A]. Patients with OCD often require higher doses of SRIs than patients with depression alone. ¾ Cognitive behavioral therapy is effective in patients with OCD and referral should be considered [A*]. ¾ MDD in patients with anorexia may be refractory to treatment until normal weight is re-established [C*]. ¾ If using antidepressants, consider use of an SRI [A*] or referral for use of an MAOI [B*]. ¾ Cognitive behavioral treatment may be more effective than other short term therapies, for patients with bulimia [A*, B*].

73 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO/DERUGLDJQRVWLN $XVJHZlKOWZHJHQGHV+LQZHLVHVZHOFKH9HUIDKUHQQLFKW]XP6WDQGDUGODERUJHK UHQ Laboratory Evaluation Use the history and physical examination findings to direct a conservative laboratory evaluation. There is no test for depression, so testing is directed toward detection of associated general medical conditions. Appropriate laboratory studies to rule out medical disorders that may cause symptoms of depression include complete blood count (CBC), chemistry profile, thyroid studies, and toxicology screen (Rosse, et al., 1995). For patients over the age of 40, an ECG may be useful. Diagnostic imaging and neuropsychological or psychological testing is not a part of the standard laboratory evaluation for depression. Proceed with the algorithm while awaiting the completion of the laboratory evaluation. EVIDENCE Brief Screening may be useful in identifying depression. (Rost, et al., 1993; U.S. PSTF, 1996) QE = II-2, SR = B ' 'LDJQRVWLNGHU)XQNWLRQVHLQVFKUlQNXQJHQ (EHQVRZLFKWLJZLHGLHGHSUHVVLYH6\PSWRPDWLNDQVLFKLVWGLHGXUFKGLH(UNUDQNXQJ EHGLQJWH(LQVFKUlQNXQJGHU$NWLYLWlWXQG)XQNWLRQVIlKLJNHLWGHV3DWLHQWHQ'LH%HXUWHLOXQJ GHU$NWLYLWlWVXQG)XQNWLRQVHLQVFKUlQNXQJLVWXQDEKlQJLJYRQGHUPHKUD[LDOHQ'LDJQRVWLN ]XEHWUDFKWHQGDLP5DKPHQGHUPHKUD[LDOHQ'LDJQRVWLN)XQNWLRQVHLQVFKUlQNXQJHQ HUKREHQZHUGHQXPHLQHP JOLFKH8UVDFKHI UGLH$XVO VXQJRGHU9HUVFKOLPPHUXQJHLQHU GHSUHVVLYHQ(SLVRGH]XILQGHQ'LH(UKHEXQJGHUGXUFKGLH(UNUDQNXQJYHUXUVDFKWHQ $NWLYLWlWVXQG)XQNWLRQVHLQVFKUlQNXQJKDWQHEHQGHU%HGHXWXQJI U3URJQRVHXQG7KHUDSLH DXFKHLQHHUKHEOLFKHVR]LDOPHGL]LQLVFKH%HGHXWXQJ8QDEKlQJLJYRQGHU]XU]HLWGLVNXWLHUWHQ (LQI KUXQJVSH]LILVFKHU(UKHEXQJVLQVWUXPHQWH]XU'LDJQRVWLNGHU)XQNWLRQVHLQVFKUlQNXQJHQ,&)HUIRUGHUWGHU$OOWDJ]%EHL%HVFKHLQLJXQJGHU$UEHLWVXQIlKLJNHLWHLQHLQGLYLGXHOOH %HXUWHLOXQJGHU)XQNWLRQVHLQVFKUlQNXQJGXUFKGHQ$U]W 3UREOHP ¾'LHYRUOLHJHQGHQ/HLWOLQLHQJHEHQQXUZHQLJJHHLJQHWH+LQZHLVHGDUDXIZLH$NWLYLWlWV XQG)XQNWLRQVHLQVFKUlQNXQJHQ]XEHVFKUHLEHQXQG]XHUIDVVHQVLQGGLHLP5DKPHQ GHSUHVVLYHU6W UXQJHQDXIWUHWHQ 9RUVFKODJ ¾(LQH/HLWOLQLHVROOWH$NWLYLWlWVXQG)XQNWLRQVHLQVFKUlQNXQJHQYRQ3DWLHQWHQEHVFKUHLEHQ GLHLP5DKPHQGHSUHVVLYHU6W UXQJHQDNXWXQGDXFKLP=XVDPPHQKDQJPLW UH]LGLYLHUHQGHQRGHUFKURQLVFKHQ9HUOlXIHQDXIWUHWHQ ¾(VVLQG+LQZHLVH]XU*HZLFKWXQJHQWVSUHFKHQGHU$NWLYLWlWVXQG)XQNWLRQVHLQ VFKUlQNXQJHQ]XJHEHQXQGHVLVWGD]X6WHOOXQJ]XQHKPHQZDQQDXVEHVWLPPWHQ )XQNWLRQVHLQVFKUlQNXQJHQZHOFKH.RQVHTXHQ]HQ]X]LHKHQVLQG]%.UDQNVFKUHLEXQJHQRGHU'LDJQRVWLNLP=XVDPPHQKDQJPLWGHU%HVWLPPXQJHLQHV %HKLQGHUXQJVJUDGHV

74 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO$VVHVVPHQWGHU)XQNWLRQVHLQVFKUlQNXQJ //9+$PDMRUGHSUHVVLYHGLVRUGHU>0RGXOH$3ULPDU\&DUH6HWWLQJ$QQRWDWLRQV $XVJHZlKOWZHLOKLHUQHEHQ=LHOHQXQGSULQ]LSLHOOHU9RUJHKHQVZHLVHDXFKDXI 0HVVLQVWUXPHQWHKLQJHZLHVHQZLUG F. Assess Functional Disability OBJECTIVE To ensure that patient has no other mental health concerns before discharge from the clinic. ANNOTATION Prior to concluding the interview and examination, the clinician should inquire about the patient s ability to carry out personal and daily activities not covered by either the chief complaint or the depression screening questions. This may be elicited in the following manner: ¾ "During the past few weeks, have any physical or emotional problems interfered with your typical daily activities? ¾ Has it been more difficult to do things on your own or with your (family, friends, neighbors, church, etc.)?" ¾ If positive, areas for brief inquiry include: job, pleasurable hobbies, social activities, and important personal relationships. As well, the clinician should ask: ¾ "Are there any other problems that we have not discussed?" If any patient responses are affirmative, the clinician should define any impediments to optimal daily functioning, recognizing that the patient may have already denied depression and substance abuse. One should be alert for alternative ways of expressing discouragement, distress, or demoralization, especially in those individuals who tend to avoid emotional words for describing themselves. Functional Status Measures 1. Global Assessment of Function (GAF) The following 0 to 100 scale (100 = maximum functioning) is the metric recommended by the American Psychological Association for measuring functional impairment due to mental disorders (DSM-IV) SF-36 Quality of Life The Short Form 36 (SF-36) is a research tool used for quantifying functional status. It is offered here to illustrate useful questions for assessing functioning in potentially depressed patients. Generally, the need for computerized scoring precludes its routine clinical use. Instructions: This survey asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. Answer every question by selecting the answer as indicated. If you are unsure about how to answer a question, please give the best answer you can...

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78 /HLWOLQLHQEHULFKW'HSUHVVLRQ ¾(LQH/HLWOLQLHVROOWHDXFKNODUEHQHQQHQZHOFKHSRWHQ]LHOOHQ3URJQRVHIDNWRUHQLQGHU :LVVHQVFKDIWGLVNXWLHUWZHUGHQGLHDEHUELVODQJRKQH5HOHYDQ]LP(LQ]HOIDOOVLQGXQG ZHVKDOEKLHUQRFKNHLQHVSH]LHOOH'LDJQRVWLNLQGL]LHUWLVW]%1HXURUDGLRORJLH %HLVSLHO+LQZHLVH]XU9HUODXIVGLDJQRVWLN $XVJHZlKOWZHJHQGHV+LQZHLVHVDXIGLH1RWZHQGLJNHLWGHU9HUODXIVGLDJQRVWLNGHU NRQNUHWHQ%HQHQQXQJYRQ8QWHUVXFKXQJVSXQNWHQXQGGHU9HUNQ SIXQJPLWNOLQLVFKHQ (PSIHKOXQJHQ Measuring Outcome The initial evaluation includes asking the patient about the nine criterion symptoms of a major depressive episode, as well as the current level of interpersonal and occupational functioning. In addition to the clinical interview, patient self-report or clinician symptom-rating scales may permit a rapid assessment of the nature and severity of depressive symptoms. Interviewing a spouse or close friend about the patient s day-to-day functioning and specific symptoms is also helpful in determining the course of the illness, current symptoms, and level of functioning. Follow-up visits during acute treatment are used to evaluate the level of symptom relief and restoration of function. Symptom evaluation (whether by interview alone or combined with the use of a symptom-rating scale) allows both practitioner and patient to assess response to treatment, determine whether the medication dosage should be adjusted, and clarify whether and when alternative treatments are needed. Declaring a Treatment Response or Failure :HLWHUH+LQZHLVHXQG%HLVSLHOH]XU'LDJQRVWLNYRQ3URJQRVHLQGLNDWRUHQ! 'LH9RUVFKOlJHXQG%HLVSLHOH]X.DSLWHO'3URJQRVHIDNWRUHQDOV$QKDOWVSXQNWGDI U I UZHOFKH)DNWRUHQGLHVH(PSIHKOXQJHQHUDUEHLWHWZHUGHQP VVHQ! 'LH9RUVFKOlJHXQG%HLVSLHOH]X.DSLWHO'7KHUDSLH]LHOHI UZLFKWLJH%HJULIIHLQGHU 9HUODXIVIRUVFKXQJ! )HUQHUJHEHQGLH.DSLWHOXQGGHU$+&35/HLWOLQLHQ>'HSUHVVLRQLQ3ULPDU\&DUH 9RO6±@EHLVSLHOKDIWH'DUVWHOOXQJHQI UGLDJQRVWLVFKH(PSIHKOXQJHQ]X 3URJQRVHIDNWRUHQGLHJOHLFK]HLWLJDXFK]XEHU FNVLFKWLJHQGHDVVR]LLHUWH(UNUDQNXQJHQ GDUVWHOOHQÄ*OHLFK]HLWLJYRUKDQGHQHZHLWHUHSV\FKLVFKH(UNUDQNXQJHQ³Ä*OHLFK]HLWLJ YRUKDQGHQHN USHUOLFKH(UNUDQNXQJHQ³XQGÄ'HSUHVVLRQLP=XVDPPHQKDQJPLW 0HGLNDWLRQ³

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80 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO$QDPQHVHLQWHUYLHZ]XU6FUHHQLQJ'LDJQRVWLN $XVJHZlKOWZHJHQNRQNUHWHU+DQGOXQJVHPSIHKOXQJI UGDV,QWHUYLHZ Personal History The patient should be questioned about any important changes in his or her personal life, such as the death of a loved one, divorce, loss of a job, or retirement. These and other psychosocial events are frequently associated with the development of symptoms which characterize depression (although the lack of such losses does not eliminate depression as a possible diagnosis). Recent research suggests that external stressors are more important in precipitating an initial occurrence of major depression, while recurrences are more likely due to neurochemicai changes in the brain. The patient should also be asked about any unusual aspects of his or her diet, tobacco use, and caffeine and alcohol consumption, each of which may be important if patient management includes drug therapy. Information regarding alcohol consumption may also suggest the need for further investigation to rule out alcohol abuse as the primary disorder or to consider the use of alcohol as self-medication by a depressed patient with anxiety symptoms. People who are depressed are more likely to use tobacco and alcohol than nondepressed individuals. They are also more likely to progress to higher levels of dependence and to be less successful in their alternate to quit: Furthermore, patients attempting to refrain form tobacco and alcohol use often suffer increased depression due to withdrawal from these substances. In addition, the patient should be asked about other forms of substance abuse, including the use of illicit drugs such as cocaine. A history of panic attacks is also important, as the incidence of depression in patients with panic disorder is increased over that of the general population. 15 Family History The family history should indicate whether close family members (parents, grandparents, children, or siblings) have a history of diagnosed mania or depression, suicide, attainted suicide, or substance abuse.16:18. If relatives have been previously diagnosed and treated for mania or depression, the record should also indicate w hat type of treatment was utilized and whether the treatment was successful. In some cases, such information may assist the physician in selecting an appropriate medication for the patient who is diagnosed as having a depressive disorder. Patient compliance with antidepressant treatment may also increase if a family member is already successfully using a particular medication. A family history of abuse (physical, sexual, substance) is also important, and appears to be associated with the development of low seif-estem and depression, particularly in women.

81 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO6FUHHQLQJ'LDJQRVWLNQDFK6FKO VVHOV\PSWRPHQ $XVJHZlKOWZHJHQGHU6XFKIUDJHQQDFK6FKO VVHOV\PSWRPHQXQWHUH[SOL]LWHQ %HU FNVLFKWLJXQJYRQ$QJVWV\PSWRPDWLNXQGDQGHUHQ8UVDFKHQGHU'HSUHVVLRQ ALGORITHM ANNOTATIONS 1. Suspect Depression and/or Anxiety... Presentations for depression and/or anxiety include: multiple (>5/year) medical visits weight gain or loss multiple unexplained symptoms sleep disturbance work or relationship dysfunction multiple worries or distress fatigue panic attacks changes in interpersonal relationships dementia Presentations particularly suggestive of an anxiety disorder include:... Physical symptoms particularly suggestive of an anxiety disorder include:... 2 Interview for Key Symptoms of Depression and Anxiety A. Depressed mood or anhedonia (diminished interest or pleasure in activities) is necessary to diagnose DEPRESSION. If you suspect depression on the basis of risk factors or common presentations, ask about depressed mood and anhedonia. Useful questions include: Are you often sad, down, blue or teary? Do you have your usual interest in and look forward to enjoyable activities? Are you able to have fun or joy? Occasionally, depressed patients will initially deny depressed mood and anhedonia. If you still suspect depression, ask about vegetative symptoms (sleep disturbances, changes in appetite and energy level). If vegetative symptoms are present, ask again about depressed mood and anhedonia. If either is endorsed, proceed to a full clinical interview. B. Anxiety and/or avoidance behavior that causes significant distress or impairment of routines are necessary to diagnose an ANXIETY DISORDER. Anxiety may occur in brief episodes (panic attacks), may be continuous (generalized anxiety disorder) or may be tied to specific situations (phobias). Most patients with panic disorder present with somatic concens, not complaints of anxiety or panic. These patients may not label their emotional distress as anxiety or panic and it may be necessary to ask in various ways about their discomfort. Brief, episodic somatic complaints reaching a peak within 10 minutes and accompanied by any sense of emotional discomfort are suggestive of panic attacks. Useful interview questions include: Are you a worrier? (Are you a high strung/nervous person?) Do you ever "out of the blue" experience an attack of intense fear of losing control, dying, fainting, "going crazy" or severe embarrassment? Are there places (e.g. shopping malls) or situations (e.g. parties) that you avoid or endure? How does your anxiety or avoidant behavior affect your daily life? Does it cause you significant distress? 5. Evaluate for Other Causes of Depression/ Anxiety A. Psychosocial Stressors... B. Medical illness The close relationship of mind and body results in the presentation of medical illness with anxiety or depression in various forms:... C. Medications and Withdrawal from Medications Reserpine, steroids,...

82 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO+LQZHLVDXI6FUHHQLQJ7RROV $XVJHZlKOWDXVLQKDOWOLFKHQ*U QGHQGDDXIGDV3UREOHPGHUhEHUWUDJEDUNHLWYRQ 3RSXODWLRQVVWXGLHQXQGGHQ*HEUDXFKYDOLGLHUWHU6FUHHQLQJLQVWUXPHQWHKLQJHZLHVHQZLUG (VIHKOWMHGRFKHLQ+LQZHLVDXIGLH)ROJHQGHV6FUHHQLQJV A. Patient Age > 18 with Suspected Depression Presenting to Primary Care DEFINITION All patients > 18 who have a positive screen for depression. DISCUSSION Depression is known to be under-diagnosed in primary care settings. There is some controversy regarding the value of screening patients in primary care settings, (U.S. PSTF, 1996; Brody DS, et al., 1998; Perez-Stable EJ, et al., 1990). Since recent studies suggest screening is feasible in primary care, the working group decided screening should be recommended (Spitzer RL, et al., 1995; Whooley MA, et al., 1997). In recognition of the evolving nature of the literature, other published validated scales can be used. Care should be taken to assure scale validation with similar patient populations as those seen in the VA and DoD settings. There are several available screening tools, each with its own strengths and problems. Appendix 1, Assessment Instruments, offers descriptions of a number of screening instruments that may also be used to quantify symptom severity and samples of these tools. Some of the validated screening tools available are listed: PRIME MD Primary Care Evaluations of Mental Disorders depression questions CES-D Center of Epidemiological Studies-Depression Scale Zung Zung Depression Rating Scale BDI Beck Depression Inventory MOS Medical Outcomes Study Depression Scale Ham-D - Hamilton Depression Scale. In all settings, a validated screening tool should be filled out before the patient sees the primary care provider, and results of the screening should be made available to the provider. Each setting should determine which screener will be adopted, at what point in the check-in process the screener will be utilized, and who will administer the screener (e.g., clerk, nurse who takes vital signs).

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89 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO,QGLNDWLRQHQI U3V\FKRWKHUDSLHDOV7HLOHLQHU.RPELQDWLRQVEHKDQGOXQJ $XVJHZlKOWZHJHQGHU EHUVLFKWOLFKGDUJHVWHOOWHQ+LQZHLVH]XU,QGLNDWLRQVVWHOOXQJXQG.RPELQDWLRQYHUVFKLHGHQHU7KHUDSLHDQVlW]H Table 14 Considerations for combines treatment A. Consider combined treatment as an initial option more strongly if: (1) History reveals a partial response to a full trial of either treatment alone. (2) Current episode of major depression is longer than 2 years. (3) patient has a history of two or more episodes with poor interepisode recovery. (4) significant psychosocial difficulties are present that interfere with adherence and indications for medications are present. (5) Patient requires it. B. Add medications to psychotherapy if: (1) Patient shows poor response to psychotherapy alone after 6 weeks or only a partial response after 12 weeks; if no response at all psychotherapy, it may be discontinued and clinical management provided. C. Add psychotherapy to medication (if medication used optimally) if: (1) Patient shows partial response to medication and residual symptoms are largely psychosological (e.g., low self-steem). (2) Patient shows partial or complete response to medication and psychosocial problems remain significant. (3) Patient has difficulty with adherence ',QWHUDNWLRQGHU%HKDQGOHUXQG9HUVRUJXQJVHEHQHQ6WXIHQSOlQH 'HU(LQEH]XJGHU9DULDELOLWlWGHSUHVVLYHU6W UXQJHQZLHVLHVLFKLQGHU5HDOLWlWYDLP 3UD[LVDOOWDJYRQ+DXVlU]WHQ]HLJWXQGGHU(LQEH]XJYRQ6SH]LILNDGHV9HUVRUJXQJVV\VWHPV PXVVEHLGHU,PSOHPHQWLHUXQJYRQ/HLWOLQLHQI UGHSUHVVLYH6W UXQJHQLQGLH9HUVRUJXQJ HLQHVWlUNHUH%HU FNVLFKWLJXQJHUIDKUHQ +LHUEHLVLQG)UDJHQQDFKGHU$EVWXIXQJGLDJQRVWLVFKHUXQGWKHUDSHXWLVFKHU0D QDKPHQ ]%MHQDFKGHP6FKZHUHJUDGGHU6W UXQJYRQ%HGHXWXQJ'LH(QWZLFNOXQJHLQHUVROFKHQ DEJHVWXIWHQ9RUJHKHQVZHLVHGKHLQHVÄ%HKDQGOXQJVNRUULGRUV³ÄSDWKZD\RIFDUH³VWHOOW HLQHQZHVHQWOLFKHQ6FKULWW]XU2SWLPLHUXQJGHU9HUVRUJXQJGHSUHVVLYHU3DWLHQWHQGDU 0RGHOOHEHLGHQHQHLQDEJHVWXIWHV.RQ]HSWGHU%HKDQGOXQJDQJHZHQGHWZXUGH]HLJWHQ +DXVlU]WHDXVI KUHQDEHUUHJHOPl LJHV\PSWRPXQGSDWLHQWHQEH]RJHQH.RQVXOWDWLRQVWHUPLQHEHLP)DFKDU]WHLQE]ZELHWHQHLQHVSH]LILVFKH8QWHUVW W]XQJGXUFK 3V\FKRWKHUDSHXWHQVRZLHLQ1RWIDOOVLWXDWLRQHQHLQHVWDWLRQlUHhEHUZHLVXQJDQ,QGHU5HDOLWlWQXW]WGHU3DWLHQWDXFKWKHUDSHXWLVFKH$QJHERWH6HOEVWPHGLNDWLRQDXV $SRWKHNHQXQG'URJHULHQ+HLOSUDNWLNHU6HOEVWKLOIHJUXSSHQGLHWHLOZHLVHXQDEKlQJLJYRQ HLQHP$U]WEHVXFKZDKUJHQRPPHQZHUGHQ'LHVH%HKDQGOXQJVLQVWLWXWLRQHQXQGVFKULWWH ZHUGHQGDKHULQYLHOHQ)l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91 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO6WXIHQSODQ]XUhEHUZHLVXQJ $XVJHZlKOWZHJHQGHU'DUVWHOOXQJGHU$XIJDEHQGHV+DXVDU]WHVXQG%HU FNVLFKWLJXQJGHU QRWZHQGLJHQLQWHUNROOHJLDOHQ=XVDPPHQDUEHLW

92 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHOhEHUZHLVXQJVNULWHULHQ $XVJHZlKOWZHJHQGHU]LHOJUXSSHQJHUHFKWHQXQGXPIDQJUHLFKHQ'DUVWHOOXQJGHU hehuzhlvxqjvnulwhulhqxqwhu%hu FNVLFKWLJXQJYRQSDWLHQWHQVHLWLJHQ)DNWRUHQ P. Unable to Treat Patient in the Primary Care Setting OBJECTIVE To assure appropriate level of care based on local resources available. ANNOTATION Many patients with major depressive disorder can be effectively treated in primary care settings. Primary care providers are strongly urged to aim for full symptom remission and to refer without unnecessary delay those patients whose symptoms are not remitting. Primary care providers vary significantly in skill, comfort, and motivation to treat major depression. Before initiating treatment, the primary care provider should weigh the need for referral to a mental health care specialist. The more specific the referring provider s consultation questions, the more successful the referral/ consultation. Reasons for referral to a specialist include the following: (AHCPR, 1993) Patient request for mental health care specialist referral/consultation Provider request for diagnostic consultation Complicating general medical problems Complicating mental disorders ( co-morbidity ) Severe, recurrent, or psychotic depression Suspected need for hospitalization Suspected need for involuntary commitment Need or patient request for psychotherapy Need for light therapy Need for electro-convulsive therapy (ECT) Questions regarding medication selection, initiation, interactions, or administration Provider concerns about patient adherence to treatment Symptom breakthrough after a positive acute phase treatment response History of poor or partial treatment response. When weighing the need for consultation, the primary care provider should take into account the common barriers to effective mental health consultation. Potential barriers may include: Patient reluctance to see a mental health care specialist Feasibility for the patient Geographical distance from consultants Length of time to consultant availability. %HLVSLHO]X:DUQKLQZHLVHQVLHKHYRUQH!%HLVSLHO:DUQVLJQDOHÄ5HG)ODJV³

93 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO%HKDQGOXQJVLQVWLWXWLRQHQ $XVJHZlKOWZHLOKLHUGLH,QGLNDWLRQHQ]XU1XW]XQJGHUYHUVFKLHGHQHQ(LQULFKWXQJHQ ]XVDPPHQIDVVHQGDXIJHI KUWVLQG Behandlungsinstitutionen Das für die Behandlung geeignete therapeutische Setting ergibt sich aus der Schwere der Symptomatik sowie den psychosozialen Umständen: ambulante Behandlung sollte bei mittelschweren bis schweren Erkrankungsepisoden in der Regel durch den psychiatrischen Facharzt erfolgen...leichte bis mittelschwere Depressionen können auch durch den entsprechend vorgebildeten Hausarzt behandelt werden. Bei Therapieresistenz und/oder suizidaler Gefährdung sollte die Überweisung an den psychiatrischen Facharzt erfolgen, der die Weiterbehandlung übernimmt bzw. ggf. die stationäre Einweisung veranlasst. Stationäre Behandlung... Teilstationäre Behandlung (Tagesklinik) ist indiziert, wenn ein tragfähiges Netzwerk fehlt und/oder eine ausreichend frequente ambulante Versorgung (noch) nicht gewährleistet werden kann bzw. unzureichend ist. Rehabilitationseinrichtungen, beschützte Wohngruppen etc. sind bei affektiven Erkrankungen nur in Ausnahmefällen notwendig, können aber bei protahierten und chronifizierten Verläufen im Anschluss eine stationären Behandlung sinnvoll sein. %HLVSLHO.RQVXOWDWLRQVQRWZHQGLJNHLW $XVJHZlKOW ZHJHQ GHU %HQHQQXQJ YRQ.RPSOLNDWLRQHQ EHL GHQHQ HLQH hehuzhlvxqj DQ HLQHQ)DFKDU]WZLFKWLJLVW Tabelle 5: Überweisung an Facharzt muß erwogen werden bei: unklarer psychiatrischer Diagnose (Nervenarzt oder Arzt für Psychiatrie) Verdacht auf weiter abzuklärende körperliche Erkrankung (Neurologe oder Internist u.a.) Multimorbidität (auch bei manchen älteren Patienten) schwerer Substanzabhängigkeit (Sorge bei hinzukommenden Absetzphänomenen) Therapieresistenz oder Notwendigkeit der Kombination von Antidepressiva mit anderen Medikamenten soweit Interaktionen befürchtet werden, z. B. Fluoxetin mit NSMRI oder niedrigpotenten Neuroleptika, Lithium mit hochpotenten Neuroleptika, klassische MAO-Hemmer mit Antidepressiva, Ersteinstellung auf Lithium, Carbamazepin oder Valproinsäure in der Rezidivprophylaxe akuter Manie depressivem Stupor, psychotischer Depression (mit ausgeprägtem Wahn) nicht ausreichend abzuschätzender Suizidgefahr Von Fall zu Fall wird die Alternative eine stationäre Behandlung sein, notfalls auch ohne fachärztliche Untersuchung

94 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO6WDWLRQlUH(LQZHLVXQJ $XVJHZlKOWZHJHQGHUNODUHQ.ULWHULHQ]XUVWDWLRQlUHQ(LQZHLVXQJ F Criteria For Inpatient Admission Admission is indicated if criterion in section A is met B or C or D is met. A. A DSM-IV diagnosis are present and complete on all 5 axes and there is evidence of significant associated social impairment, occupational impairment or subjective suffering. B. The patient is danger to him/hereself such as might be indicated by one or more of the following: High lethality or high-intent suicide attempt in past two weeks Recent suicide gesture in patient with history of high lethality or high-intent suicide attempt Suicidal ideation with a plan, in the presence of command hallucinations, delusions of guilt or impending death, intractable ain, feelings of depression or hopelessness or other known precipitant of suicide Persistent acts of self-mutilation Medical emergencies influenced by mental illness Inability to provide for on basic needs of food, shelter or medical care as the result of mental illness Bizarre behavior due to a psychotic disorder that endangers patient, his/her reputation, assets or relationship C. The patient is danger to others as a result of mental disorders that is likely to improve by hospitalization, as evidenced by one or more of the following: Threats of harm against a specific individual associated with a delusional thought pattern or persistent anger/agitation Threats of harm against an unidentified person(s) Threatening behavior with a lethal weapon or possession of a lethal weapon in a state of emotional disturbance Escalating threatening language or behavior in a patient with history of assaultive or aggressive behavior Significant damage to property D The patient has a serious mental disorder causing significant impairment of social, familial, vocational or educational functioning that would benefit from the intensity of acute treatment, such as: Depressed mood disabling vegetative symptoms Marked deterioration in personal hygiene as a result of an acute psychiatric disorder Complete withdrawl from work, school or social situations due to an acute psychiatric disorder

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96 /HLWOLQLHQEHULFKW'HSUHVVLRQ 9RUVFKODJ ¾'LH0D QDKPHQGHU3DWLHQWHQHGXNDWLRQ3DWLHQWHQI KUXQJVROOWHQLP5DKPHQGHU (LQRUGQXQJGHU7KHUDSLHYRQVSH]LILVFKHQSV\FKRWKHUDSHXWLVFKHQ0D QDKPHQVLHKH.DSLWHO'3V\FKRWKHUDSLHYHUIDKUHQNODUXQGP JOLFKVWHLQGHXWLJYRQGLHVHQ DEJHJUHQ]WZHUGHQGDEHLLVWDXFKDXIEHVRQGHUH$QIRUGHUXQJHQEHLGHU /HLVWXQJVHUEULQJXQJ]%$EUHFKQXQJVPRGDOLWlWHQ4XDOLILNDWLRQVYRUDXVVHW]XQJHQ KLQ]XZHLVHQ ¾(EHQVRLVWHLQH$EJUHQ]XQJGHUÄ3V\FKRHGXNDWLRQ³YRQFXUULFXODUHQ 6FKXOXQJVPD QDKPHQVLHKH.DSLWHO'YRU]XQHKPHQ ¾(LQH/HLWOLQLHVROOWHSUDNWLVFKH2ULHQWLHUXQJVKLOIHQ]XU'LDJQRVHDXINOlUXQJGHV3DWLHQWHQ JHEHQ'DEHLVROOWHGDUJHVWHOOWXQGWKHRUHWLVFKEHJU QGHWZHUGHQZRU EHUHLQ$U]WZDQQ XQGPLWGHP3DWLHQWHQUHGHQVROOWH ¾(VLVWHLQH6WHOOXQJQDKPHHUIRUGHUOLFKREXQGXQWHUZHOFKHQ8PVWlQGHQXQG*HIDKUHQ XQGZLHODQJHGLH0LWWHLOXQJGHU'LDJQRVHÄ'HSUHVVLRQ³LP+LQEOLFNDXIGLHHUIRUGHUOLFKH (WDEOLHUXQJHLQHVWKHUDSHXWLVFKHQ$UEHLWVE QGQLVVHVDEJHZDUWHWZHUGHQNDQQ(VLVW GDEHLIHVW]XOHJHQZLHGDV*HVXQGKHLWVSUREOHPLP)DOOHGHU9HU] JHUXQJGHU 'LDJQRVHPLWWHLOXQJDQGHQ3DWLHQWHQNODVVLIL]LHUWXQGJHJHQ EHUGHP3DWLHQWHQ EHVFKULHEHQZHUGHQVROO ¾(LQH/HLWOLQLHVROOWHDXIJHHLJQHWHTXDOLWDWLYKRFKZHUWLJHHYLGHQ]EDVLHUWH 3DWLHQWHQLQIRUPDWLRQHQGLHGDVQRWZHQGLJH:LVVHQ EHU'LDJQRVHXQG7KHUDSLH YHUPLWWHOQXQGGLHGDVHPSIRKOHQH9RUJHKHQXQWHUVW W]HQYHUZHLVHQ)HUQHUVLQG +LQZHLVH]XPJH]LHOWHQ(LQVDW]GHU3DWLHQWHQLQIRUPDWLRQHQLP5DKPHQGHU 3DWLHQWHQI KUXQJ]XJHEHQ %HLVSLHO$EJUHQ]XQJGHU3DWLHQWHQI KUXQJ]XU3V\FKRWKHUDSLH $XVJHZlKOWZHJHQGHV9HUZHLVHV]XU$EJUHQ]XQJYRQ3V\FKRWKHUDSLHXQGGHQ XQWHUVW W]HQGHQ0D QDKPHQGHVÄFOLQLFDOPDQDJHPHQW&0³ INTRODUCTION Psychotherapy refers to the psychological treatment of psychiatric and behavioural disorders that is enacted through the establishment of a professional relationship with a patient for the purpose of alleviating existing symptoms and preventing the recurrence of maladaptive patterns of behaviour. The nature of supportive therapy, or clinical management (CM), is discussed in a previous article (see Section II); this section will deal with specific psychotherapy models.... %HLVSLHO,QIRUPDWLRQ]XU.UDQNKHLWVHLQVLFKW //:+2±8.>6@ $XVJHZlKOWZHJHQGHU'DUVWHOOXQJGHUZHVHQWOLFKHQ(OHPHQWHGHU.UDQNKHLWVLQIRUPDWLRQ Essential information for patient and family Depression is a common illness and effective treatments are available. Depression is not weakness or laziness. Depression can affect patients ability to cope. Recommend information leaflets or audiotapes to reinforce the information.

97 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO$OOJHPHLQHV%HUDWXQJV0RGXO $XVJHZlKOWZHJHQGHU1HQQXQJGHU=LHOHGHU3DWLHQWHQLQIRUPDWLRQ]XGHQ 7KHUDSLHP JOLFKNHLWHQ O. Discuss Treatment Options and Patient s Preferences. Provide Patient/family Education OBJECTIVE To provide the patient and significant others an understanding of the available treatment options. ANNOTATION There are four broad treatment options for patients with MDD. These are: 1. Pharmacotherapy including other somatic therapies, including Electroconvulsive Therapy (ECT) 2. Empirically Supported Psychotherapies (EST) 3. Combined psychotherapy and pharmacotherapy 4. Clinical evaluation of one to three visits. Patients should be educated about the potential consequences of untreated MDD, and encouraged to return. DISCUSSION A balanced presentation of the relative benefits and drawbacks of each approach should be provided, to help the patient and provider make a reasoned decision about which approach to select.

98 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO6SH]LILVFKHV%HUDWXQJV0RGXO $XVJHZlKOWZHJHQGHUVSH]LILVFKHQ EHUVLFKWOLFKHQ'DUVWHOOXQJGHU,QKDOWHGHV $XINOlUXQJVJHVSUlFKHV Benefits of pharmacotherapy include: Potential of a more rapid initial treatment response 1. Patient s preference for medications over talk therapies. Risks or drawbacks of pharmacotherapy include: 1. Need to take medications consistently and exactly as prescribed. Potential for medication side-effects or interactions with other medications or medical problems. Potential for need to take medication for an indefinite or extended period. Psychotherapy This is the use of one of the ESTs, offered in either one-on-one or group format.... Benefits of psychotherapy include: 1. Effects may persist beyond the duration of treatment. The need to take antidepressant medications or experience medication side effects may be reduced. An opportunity for the patient to make meaningful self-improvements or life changes. Risks or drawbacks of psychotherapy include: 1. Patients need to come consistently for therapy appointments on a frequent basis for several months at a time 2. A therapist trained in an empirically supported psychotherapy may not be available in every care setting. Q. Is Psychotherapy Preferred, Appropriate and Available? OBJECTIVE To determine the best treatment option for the patient. ANNOTATION Psychotherapy for depression is generally appropriate for all forms of depression managed in the primary care setting. Because there are no demonstrated differences in outcome between patients treated with psychotherapy or pharmacotherapy, patient choice should be strongly considered in treatment planning. Collaborative management of depressed patients with a mental health specialist, especially those with persistent symptoms, can increase the cost effectiveness of care and may be useful for patients who refuse off-site mental health and consultation. (Katon, 1996; Katon, 1995; Von Korff, et al., 1998; Katon, 1999). Utilization of mental health specialists affiliated with a primary care center will facilitate communication, joint management, and more convenience for the patient. Availability of a competent psychotherapist is a prerequisite for the psychotherapy option. It has been shown, for example, that the competency of the psychotherapist affects treatment effectiveness (Jacobson & Hollon, 1996). Variability in the quality of administration of all treatments affects the patient s outcome for both medication and psychotherapy. Combination of an empirically-supported psychotherapy with medication has not been shown to produce consistently better outcomes for most patients than use of one of these approaches on its own. However, addition of cognitive-behavioral therapy to medication has been shown to reduce risk of relapse (Fava et al., 1994; Rush & Hollon, 1991). EVIDENCE... R. Is Pharmacotherapy Appropriate and Is Patient Willing to Take Medications? OBJECTIVE To determine whether the patient should receive a pharmacological intervention. ANNOTATION Generally patients should receive antidepressant medications for the following indications: Moderate or severe symptoms of depression Significant impairment in social or occupational functioning due to depression Suicidal ideation Strong indications for antidepressant medication include: Past history of a positive response to medications Negative response to psychotherapeutic interventions Recurrent depressive episodes Family history of depression Patient preference for drug therapy

99 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO/HEHQVVWLOlQGHUXQJ $XVJHZlKOWZHJHQGHU EHUVLFKWOLFKHQ'DUVWHOOXQJYRQWKHUDSHXWLVFKHQ0D QDKPHQ]XU /HEHQVVWLOlQGHUXQJ Lifestyle There is research that suggests that lifestyle changes may help to: reduce the risk of recurrence of mild to moderate unipolar Major Depressive Disorder relieve symptoms of mild to moderate Major Depressive Disorder possibly reduce the risk of moderate Major Depressive Disorder becoming more severe. Lifestyle changes that have been shown to be of some benefit include: stress management (Aro, 1994) reducing drug and alcohol use abuse of alcohol (Schuckit, 1994; Bartels et al, 1992; Petty, 1992) has been associated with increased rates of Major Depressive Disorder. A person who is depressed should ideally stop using alcohol or at least reduce consumption to no more than two standard drinks a day and no more than one standard drink per hour. Note that other drugs, such as cannabis, can also have an effect on mood and their consumption should be discouraged, especially if the person is taking medication. sleep patterns there is some evidence for a relationship between the disruption of circadian rhythms and Major Depressive Disorder (Healey and Williams, 1988; Linkowski and Mendlewicz, 1993). The development and maintenance of good sleep patterns may be an important adjunct for the treatment of Major Depressive Disorder and prevention of relapse. a balanced diet ensure that the person has a balanced diet which includes complex carbohydrates and vitamins. Some evidence exists that carbohydrate-enriched foods improve mood (Wurtman, 1993; Wallin and Rissanen, 1994). physical exercise Martinsen (1994) reviewed ten experimental and two quasi-experimental studies and concluded that despite some methodological shortcomings, all studies point in the direction of aerobic exercise being more effective than no treatment. People may find it hard to implement lifestyle changes while continuing to experience depressive symptoms and should be encouraged to make changes as and when possible. %HLVSLHO(GXNDWLRQ]XU3UREOHPO VXQJ //1$&>6@ $XVJHZlKOWZHJHQGHU1HQQXQJGHU9RUDXVVHW]XQJHQ]XU$QZHQGXQJGLHVHV9HUIDKUHQVLQ GHU3UD[LV Problem solving Problem solving treatment has been shown to be effective, feasible and acceptable to patients as a treatment for Major Depressive Disorder in primary care. In one study it was found that problem solving was as effective as amitriptyline, (a tricyclic anti-depressant) and more effective than a placebo when given over six sessions by general practitioners who have taken a short course to learn the relevant skills. Patient satisfaction was high and showed a low drop-out rate (Mynors-Wallis et al, 1995). Problem solving interventions teach the person to use their own skills and resources to cope with both present and future problems. It has several stages: 1. identifying and clarifying the problem 2. setting clear achievable goals 3. brainstorming to generate solutions 4. selecting the preferred solution 5. evaluating progress. Training in problem solving for general practitioners includes a short theoretical course that entails reading relevant papers, role playing in clinical scenarios, and watching a training videotape.

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102 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHOhEHUVLFKW EHU3V\FKRWKHUDSLHQXQGYHUJOHLFKHQGH'DUOHJXQJGHU(IIHNWLYLWlW $XVJHZlKOWZHJHQGHUNODUHQHYLGHQ]EDVLHUWHQ$XVVDJHQPLW$EVWXIXQJGHU(PSIHKOXQJHQ QDFKPHWKRGLVFKHU(YLGHQ]VWlUNH'DEHLZLUGDXFKDXIIHKOHQGH%HOHJH]XP1XW]HQ EHVWLPPWHU7KHUDSLHIRUPHQXQGGHU(LJQXQJYRQVSH]LILVFKHQ3V\FKRWKHUDSLHQEHL VSH]LILVFKHQ6XEJUXSSHQYHUZLHVHQ Recommendations for Individual Psychotherapies (see Table 3.1) First-line treatments Cognitive therapy (CT) or cognitive-behavioural therapy (CBT) (Level 1 evidence). Interpersonal therapy (IPT) (Level 1 evidence). At mild-to-moderate levels of severity, these treatments have efficacy comparable with medications, but they may be less effective in severe depression. Second-line treatments Behaviour therapy (BT) (Level 1 evidence). This treatment is usually incorporated in a CBT approach. Third-line treatments Brief dynamic psychotherapy (BDP) (Level 2 evidence). There is insufficient evidence to recommend long- term psychodynamic psychotherapy for the treatment of depression.... Recommendations for Group Therapy and Marital Therapy (see Table 3.1) First-line treatments Group formats of cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT) (Level 2 evidence). There is less evidence for efficacy of group, compared with individual, forms of psychotherapy. Individual therapy may be more effective than group therapy for more severe depressions. Second-line treatments Marital or couples therapy, in patients with significant marital distress (Level 2 evidence).... Recommendations for Psychotherapy in the Treatment of Chronic Depression or Dysthymic Disorder (see Table 3.1) First-line treatments Concurrent, combined psychotherapy and pharmacotherapy for chronic depression or dysthymic disorder (Level 2 evidence). The psychotherapies that have been evaluated are cognitive-behavioural analysis system of psychotherapy (CBASP), cognitive-behavioural therapy (CBT), and interpersonal therapy (IPT). Pharmacotherapy alone (Level 2 evidence). The medications that have been evaluated are nefazodone and sertraline. Second-line treatments CBASP alone for chronic depression (Level 2 evidence). Not Recommended Psychotherapy alone (CBT, IPT) is not recommended for dysthymic disorder because of evidence of lack of efficacy (Level 2 evidence).

103 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO&KDUDNWHULVLHUXQJGHU]HQWUDOHQ=LHOHXQGGHV9RUJHKHQVEHLNRJQLWLYHQ 9HUKDOWHQVWKHUDSLHQ $XVJHZlKOWZHLOGLHZLFKWLJVWHQ=LHOHXQG%HKDQGOXQJVSULQ]LSLHQEH]RJHQDXI XQWHUVFKLHGOLFKH6WDGLHQGHU$NXWWKHUDSLHGDUJHVWHOOWZHUGHQ'LH'DXHUXQG$EIROJHGHU 6LW]XQJHQVLQGVSH]LILVFKHQ7KHUDSLHSKDVHQXQG=LHOHQ]XJHRUGQHWZRUGHQ 'LH%HZHUWXQJGHU:LUNVDPNHLWVQDFKZHLVHLVWLP%HLVSLHOGDUJHOHJW 2. What are the general principles of cognitive therapy and behaviour therapy? Cognitive therapy (CT) pursues symptomatic relief from depression through a systematic effort to change depressed patients automatic and maladaptive ways of thinking. At the heart of this approach is the assumption that distorted beliefs about the self, the world, and the future maintain depressive affect. Patients first work at becoming aware of these thinking styles and then learn how to respond to them in ways that are more adaptive. These skills, when accompanied by affective arousal and practised in the context of extra therapy assignments, are an important engine of symptom change (3). The typical course of treatment runs from 12 to 16 sessions, and the sequence of treatment involves 3 phases. In the early phase (sessions 1 to 4), the emphasis is on establishing a therapeutic relationship with the patient, educating the patient about the cognitive model and influences on emotion, setting goals, and eliciting and evaluating automatic thoughts. The middle phase (sessions 5 to 12) involves a gradual shift to ward the identification of dysfunctional beliefs and compensatory strategies the patient may be employing, helping the patient to identify core beliefs, and practising skills at responding to and modifying depressogenic views. Tasks in the late phases of CT (sessions 13 to 16) revolve around preparing the patient for termination, predicting high- risk situations relevant to relapse, and consolidating learning through self-therapy tasks. Behaviour therapy (BT) for depression is premised on the observation that patients with a mood disorder are ex posed to fewer positive reinforcers in their environments (4,5). Behavioural interventions are especially effective for symptoms of social withdrawal and anhedonia and are often used in tandem with cognitive strategies (for example, CBT). An important goal of behavioural treatment is to increase patients activity levels and engage patients in tasks to in crease their feelings of mastery and pleasure. In the early stages, patients are asked simply to monitor their activities and to rate the degree of difficulty and satisfaction associated with completing or attempting each task. As treatment progresses, patients are asked to perform, as home work assignments, a greater number of pleasurable activities or events. Training in social skills and assertiveness might also enhance the patient s interpersonal repertoire and reduce the number of aversive, submissive interactions with others. Toward the end of treatment, the focus shifts to selfcontrol training and problem solving, so that the learning achieved in therapy can be generalized and sustained in the patient s social environment (6). BT is now usually incorporated with CT as CBT.

104 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO&KDUDNWHULVLHUXQJGHU]HQWUDOHQ=LHOHXQGGHV9RUJHKHQV,QWHUSHUVRQHOOHU 3V\FKRWKHUDSLH $XVJHZlKOWZHLOGLHZLFKWLJVWHQ=LHOHXQG%HKDQGOXQJVSULQ]LSLHQEH]RJHQDXI XQWHUVFKLHGOLFKH6WDGLHQGHU$NXWWKHUDSLHGDUJHVWHOOWZHUGHQ'LH'DXHUXQG$EIROJHGHU 6LW]XQJHQVLQGVSH]LILVFKHQ7KHUDSLHSKDVHQXQG=LHOHQ]XJHRUGQHWZRUGHQ 'LH%HZHUWXQJGHU:LUNVDPNHLWVQDFKZHLVHLVWLP%HLVSLHOGDUJHOHJW 4. What are the general principles of IPT? IPT for depression pays careful attention to changes in patients interpersonal environment and their relation to the onset of mood disorder. The basic assumption is that addressing relation shipissues, whether they are contributing factors or consequences of depression, will lead to improvement in depressive symptoms. Patients are encouraged to facilitate affective expression, especially emotions related to mourning or loss of social roles. Other strategies also employed include analyzing blocks in communication with significant others, problem solving aimed at resolving disputes, and social skills training aimed at reducing social isolation (25). The course of treatment in IPT has 3 phases over 12 to 16 sessions. In the early phase (sessions 1 to 3), the therapist explains the rationale for depression, using a medical model, and for treatment focusing on interpersonal difficulties the patient might behaving. Once are view of the patient s major interpersonal relationships and the onset of depressive symptoms is completed, IPT moves into its middle phase (sessions 4 to 12). At this point, the therapist and patient decide to focus on 1 or 2 of 4 important inter personal problem areas that are thought to be contributing to the depression: unresolved grief, role disputes, role transitions, and social isolation. Specific strategies are used to address each problem area, focusing on the patient s life out side the office. The termination phase of IPT (sessions 13 to 16) is devoted to reviewing the course of treatment and reinforcing progress. Termination is ad dressed as early as session 12, and the therapist helps the patient prepare for the event by eliciting relevant thoughts and feelings. The therapist emphasizes competence and frames any challenges to be met in terms of using new learning to reduce vulnerability to future depression (26).

105 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHOhEHUVLFKW EHUGLH(IIHNWHYRQ.RPELQDWLRQVWKHUDSLHQ $XVJHZlKOW ZHJHQ GHU H[SOL]LWHQ 1HQQXQJ XQG EHUVLFKWOLFKHQ =XVDPPHQVWHOOXQJ YRQ 3DWLHQWHQJUXSSHQEHLGHQHQHLQH.RPELQDWLRQVWKHUDSLHHPSIRKOHQZLUG Recommendations for Concurrent Combined Treatment (see Table 5.2) Acute-phase treatment. Concurrent combined treatment is not recommended because there is no evidence for greater efficacy than that achieved with psychotherapy or pharmacotherapy alone (Level 2 evidence), except in the following circumstances: First-line treatment Chronic depression: cognitive-behavioural analysis system of psychotherapy (CBASP) plus nefazodone is more effective than either treatment alone (Level 2 evidence). Severe depression: interpersonal therapy (IPT) plus pharmacotherapy may be more effective than either treatment alone (Level 1 evidence). Maintenance-phase treatment Concurrent combined treatment is not recommended because there is no evidence for greater efficacy than that achieved with psychotherapy or pharmacotherapy alone (Level 2 evidence), except in the following circumstances: First-line treatment Elderly patients: IPT plus nortriptyline may reduce relapse rates, compared with either treatment alone, in patients treated with the combination in the acute phase (Level 2 evidence).... Recommendations for Sequential Combined Treatments (see Table 5.2) There is limited evidence to support a sequential combined strategy; that is, adding psychotherapy or pharmacotherapy to patients who show nonresponse or partial response to monotherapy. Second-line treatment Adding cognitive- behavioural therapy (CBT) for patients with residual depressive symptoms after acute treatment with pharmacotherapy improves remission rates and reduces relapse/recurrence rates (Level 2 evidence). Adding pharmacotherapy for women with partial or no response after acute treatment with interpersonal therapy (IPT) may improve remission rates (Level 3 evidence). %HLVSLHO,QGLNDWLRQXQG.ULWHULHQI U3V\FKRWKHUDSLHDOVHUVWHU%HKDQGOXQJVDOWHUQDWLYH //1$&>6@ $XVJHZlKOW ZHJHQ GHU XQWHUVFKLHGOLFKHQ,QGLNDWLRQVJHVLFKWVSXQNWH XQG GHU =XRUGQXQJ ]X =LHOHQ Table 6. Indications for the selection of an appropriate psychological therapy Adapted from Table 10, Major Depressive Disorder in Primary Care: Volume 2. Treatment of Major Depressive Disorder. Agency for Health Care Policy and Research, US Department of Health and Human Services, Primary Objectives Examples 1. Symptom removal Cognitive-Behavioural and Interpersonal Psychotherapy 2. Restoration of normal psychosocial and occupational functioning Case management; Cognitive-Behavioural, psychoeducational, occupational, marital or family therapy 3. Prevention of relapse/recurrence Maintenance therapy (Cognitive-Behavioural, interpersonal, other) 4. Correction of "causal" psychological problems with secondary Marital, family, cognitive, interpersonal, brief dynamic, and other symptom resolution therapy 5. Increased adherence to medication Clinical case management; specific Cognitive-Behavioural, or other psycheducational techniques or packages. 6. Correction of secondary consequences of the major Depressive Occupational, marital, family interpersonal, cognitive therapy, other Disorder (eg marital discord, low selfesteem) therapies focused on specific problems.

106 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO,QGLNDWLRQHQXQG.ULWHULHQI U3V\FKRWKHUDSLHDOV7HLOHLQHU.RPELQDWLRQVEHKDQGOXQJ $XVJHZlKOWZHJHQGHUNRQNUHWHQ%HQHQQXQJYRQ,QGLNDWLRQVEHUHLFKHQ Combining antidepressants with psychological therapies There is evidence for combining psychological therapies with the use of antidepressants and clinical management in cases where: the prior course of the illness is chronic or characterised by poor inter-episode recovery (for example Dysthymic Disorder with acute Major Depressive Episodes) where antidepressants alone have been only partially effective and where negative cognitions (pessimistic thoughts), low self-esteem and/or relationship difficulties are identified where there is a history of chronic psychosocial problems, both during and between episodes of Major Depressive Disorder where there is a history of reluctance to persist with treatment when there are residual symptoms that are largely psychological. %HLVSLHO/DQJ]HLWWKHUDSLH //&3$>6@ $XVJHZlKOWZHJHQGHUVSH]LILVFKHQ(PSIHKOXQJHQ]XU/DQJ]HLWWKHUDSLH Recommendations for Psychotherapy as Maintenance Treatment (see Table 3.1) There is limited evidence to recommend psychotherapy as maintenance treatment. There may be some carry- over effects of acute-phase treatment with cognitive-behavioural therapy (CBT) and interpersonal (IPT) that offer modest protection against relapse (Level 2 evidence). Maintenance therapy sessions for CBT and IPT may reduce relapse rates, although there is insufficient evidence about the optimal frequency and duration of maintenance sessions (Level 2 evidence). %HLVSLHO3V\FKRWKHUDSLH]XU5H]LGLYSURSK\OD[H/DQJ]HLWWKHUDSLH $+&35>9RO6@ $XVJHZlKOWZHJHQGHU)RUPXOLHUXQJGHU9RUDXVVHW]XQJHQ]XU)RUWI KUXQJGHU 3V\FKRWKHUDSLH 9 Guideline: Continuation and Maintenance Treatment Options Objectives and Indications for Continuation Treatment Guideline: A decision to implement continuation phase psychotherapy depends on the patient s residual symptoms, psychosocial problems, history of psychological functioning between episodes, and the practitioner s and patient s judgment about the need for such treatment. Continuation psychotherapy can be added to continuation medication following acute phase response to either medication alone or the combination. (Strength of Evidence = C.)

107 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO7KHUDSLHEHJOHLWHQGH'RNXPHQWDWLRQ $XVJHZlKOWZHJHQGHV$QVSUHFKHQVGHU1RWZHQGLJNHLWGHUWKHUDSLHEHJOHLWHQGHQ 'RNXPHQWDWLRQXQGGHU1HQQXQJYRQHUJlQ]XQJVEHG UIWLJHQ,QVWUXPHQWHQ Monitoring The frequency and method of monitoring each person s depressive condition should be decided in consultation with them. Ideally a balance should be sought which minimises intrusiveness and cost to the individual while ensuring that the health professional has reliable and accurate information about the treatment response, any negative side effects that may reduce compliance and any significant alteration in the stressors or supports which may worsen the depressive disorder. Monitoring will be most effective if carried out in the context of an open and honest relationship. Regular (weekly or fortnightly) monitoring is best done by the same person who should have appropriate clinical training and experience. Regular (less frequent) monitoring should continue for at least 12 months from the recovery from a depressive episode and the cessation of medication. The most accurate means of monitoring the person s mood is to use one of the rating scales provided in Appendices 3 to 5 (Hamilton, CES-D or Edinburgh Postnatal Major Depressive Disorder Scale). These rating scales take as little as 5-10 minutes to complete, ensure all aspects of the depressive disorder are considered and provide the opportunity to make a comparison over time. The Hamilton rating scale is the most comprehensive and is best carried out as part of a face to face consultation. The CES-D provides a reliable estimate of the level of Major Depressive Disorder and is suitable for use by nurses and counsellors. The CES-D can also be used in the course of a telephone call or in some cases completed by the person themselves and delivered to the health centre.... %HLVSLHO=HLWSXQNWHXQG.ULWHULHQ $+&35>9RO66@ $XVJHZlKOWZHJHQGHV+LQZHLVHVDXINRQWLQXLHUOLFKH%HREDFKWXQJGHU6\PSWRPDWLNXQGGLH 1HQQXQJ NRQNUHWHU =HLWNULWHULHQ I U GDV,QEHWUDFKW]LHKHQ ZHLWHUHU 7KHUDSLHRSWLRQHQ LQVEHVRQGHUHGHV:HFKVHOV]X0HGLNDPHQWHQ 5 Guideline: Acute Phase Management with Psychotherapy Objectives and Indications (S.73 ) Guideline: As with a medication trial, if psychotherapy alone is selected as the initial treatment, the practitioner is advised to monitor symptom response. If the psychotherapy is completely ineffective by 6 weeks or if it does not result in nearly a full symptomatic remission within 12 weeks, a switch to medication may well be appropriate since there is clear evidence of its specific efficacy. (Strength of Evidence = A.)... 6 Guideline: Acute Phase Management with Medication and Psychotherapy Objectives and Indications (S. 88) It is recommended that medication be added to (or substituted for) acute phase psychotherapy if: There is no response at all to psychotherapy alone at approximately 6 weeks. There is only a partial response to an adequate 12-week trial of psychotherapy. The patient worsens with psychotherapy alone. The patient requests medication during or following psychotherapy and symptoms are appropriate and sufficient to warrant medication.

108 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO6HWWLQJVSH]LILVFKH%HVRQGHUKHLWHQ $XVJHZlKOWZHJHQGHU(YLGHQ]EDVLHUXQJGHULQKDOWOLFKHQ$XVVDJHQ(VZLUGKLHUMHGRFKQXU GHU(LQIOXVVHLQHPYRQYLHOHQGHQNEDUHQ6HWWLQJIDNWRUHQDXIGLH:LUNVDPNHLWEHVFKULHEHQ Providing treatment to patients with depression in groups, rather than individually, has several potential advantages: group therapy may be more cost-effective; there is destigmatization in viewing other people who are struggling with the same set of problems; group sessions allow patients the opportunity to role play and practise new interpersonal behaviours and skills, and the group approach may assist patients in the application of these new skills (42). There are some data to support both modifications of CT and IPT delivered as a group based treatment for depression (43,44). In a review of efficacy studies comparing group therapy and individual therapy reported in 1986, no significant differences in efficacy were found in 24 (75%) of the 32 studies(45). In the remaining 8 studies (25%), group therapy was found to be more effective than individual treatment. Studies included in this review, however, represented a broad range of diagnoses not restricted to mood disorders, and no clear pattern emerged regarding efficacy in specific conditions. A subsequent selective review of group therapy in depressive disorders, published 5 years later, suggested that group therapy was an effective short-term treatment for outpatients with milder forms of depression but that individual therapy may be more effective than group therapy for more severe depression (46). Similarly, in a metaanalysis of 23 studies, no overall differences were found between group and individual therapies, but in the 4 studies of depression, there was a trend favouring individual therapies over group therapies (47). %HLVSLHO,QIRUPDWLRQ]XU$XVZDKOYRQ7KHUDSHXWHQ //&3$>6I@ $XVJHZlKOWZHJHQGHU+LQZHLVHZRPDQVLFK EHU7KHUDSLHYHUIDKUHQLQIRUPLHUHQNDQQ S30 2. What are the general principles of cognitive therapy and behaviour therapy? CBT for depression is still a relatively new form of brief psychotherapy, and so the resources available to patients seeking treatment may be limited. Identifying a qualified cognitive-behavioural therapist can be facilitated through The Academy for Cognitive Therapy ( myofct.org). There are also several userfriendly CBT patient manuals that can be recommended to patients or referred to by psychiatrists who use elements of CBT in their therapeutic approach. These include Mind over Mood (7) and The Feeling Good Handbook (8).... S What are the general principles of IPT?... IPT is also a relatively new form of brief psychotherapy for depression, and the resources available to patients seeking treatment are limited. Are source for interested psychiatrists and patients is the standard textbook for IPT, A Comprehensive Guide to Interpersonal Psychotherapy (27).

109 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO4XDOLILNDWLRQVYRUDXVVHW]XQJHQYRQ7KHUDSHXWHQ $XVJHZlKOWZHJHQGHUH[SOL]LWHQ'DUVWHOOXQJGHU9RUDXVVHW]XQJHQDXI7KHUDSHXWHQVHLWH Psychological therapies... Professionals who are competent to provide specialised psychological therapies outlined in these guidelines would have the following attributes: a tertiary qualification which included a theoretical understanding of personal and interpersonal behaviour, dysfunction and techniques for effecting change; have undertaken personal development examining their own values, beliefs, emotions and relationships; satisfactorily completed experiential learning of skills required to apply appropriate techniques to change mood and behaviour; be a current member of a professional association which has acceptable ethical standards and disciplinary procedures; and have ongoing professional supervision to maintain the quality of their work. These professionals will typically be psychiatrists, psychologists, psychotherapists or qualified counsellors (Refer to Appendix 9 for a list of professional bodies involved in psychological therapy). %HLVSLHO9RUJDEHQ]XU$XVZDKOGHV7KHUDSHXWHQEHL(LQOHLWXQJHLQHU3V\FKRWKHUDSLH //1$&>6I@ $XVJHZlKOWZHJHQGHU%HQHQQXQJGHUEHLGHUhEHUZHLVXQJ]XU3V\FKRWKHUDSLHUHOHYDQWHQ *HVLFKWVSXQNWH The psychological therapies referral When psychological therapy is selected as a treatment, the following principles may be useful: the referral should be made to therapists who are experienced and trained to work with people with depressive disorders 26, such as clinical psychologists, psychiatrists, psychotherapists, and qualified counsellors. It is strongly recommended that referrals are only made to therapists who are members of a recognised professional organisation which has documented ethical guidelines, professional conduct procedures and requirements for supervision in making a referral it is important to consider the ethnic and cultural background of the therapist and other factors influencing the effectiveness of psychological therapies outlined earlier it is helpful when making a referral to indicate the needs of the person and their suspected problem areas, the expectations of the referral and the ongoing responsibilities for management and crisis management the psychological therapy should generally be time-limited, focused on those current problems identified with the depressed person and aimed at symptom resolution assessment of symptom response is useful for planning the next step in treatment. To ensure that adequate feedback is received from the therapist, the referrer should specify that they want a report on progress, after a specified period of time. This sharing of information should be done with the person s consent but also in accordance with accepted principles of confidentiality. Where issues of safety are relevant, client consent is desirable but not mandatory (Privacy Act) there is a need to measure and monitor the outcome of psychological therapies whenever treatment is initiated. This is especially important if psychological therapies alone are being used and the person fails to show any improvement in depression by six weeks, or marked improvement by twelve. In such situations, a re-evaluation of the process, in conjunction with the therapist, should occur. 26 Organisations that are able to supply a list of therapists who are experienced and appropriately trained include the New Zealand Psychological Society, New Zealand Association of Counsellors, New Zealand Association of Psychotherapists, the New Zealand Association of Social Workers, the New Zealand College of Clinical Psychologists and the New Zealand Association of Child Psychotherapists. Universities or Polytechnics who have training programmes for clinicians may also be a source of information on appropriate practitioners. Community Mental Health Centres are also a source of information, as well as offering the assessment and treatment skills of a multidisciplinary team for moderately and severely depressed people. =XVDPPHQVWHOOXQJZLFKWLJHUÄSV\FKRHGXNDWLYHU,QIRUPDWLRQHQ³ VLHKH.DSLWHO'6FKXOXQJYRQ3DWLHQWHQXQG$QJHK ULJHQGLH $QIRUGHUXQJHQDQ,QIRUPDWLRQHQ]X.UDQNKHLWXQG.UDQNKHLWVYHUODXI

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113 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO'RVLHUXQJVHPSIHKOXQJHQ $XVJHZlKOWZHLOKLHUHLQHJXWHXQG EHUVLFKWOLFKH'DUVWHOOXQJGHUHLQ]HOQHQ0HGLNDPHQWH DQJHJHEHQLVW%HOHJHI UGLH:LUNVDPNHLWXQGGLH%HZHUWXQJGLHVHU%HOHJHZHUGHQMHGRFK QLFKWGDUJHOHJW'LHLQGHU7DEHOOHHUZlKQWHQSKDUPDNRORJLVFKHQ%H]HLFKQXQJHQE]ZGHUHQ $EN U]XQJHQZHUGHQDQJHVRQGHUWHU6WHOOHHUOlXWHUW Tabelle 6: Antidepressiva: Stoffgruppen, Einzelsubstanzen, Dosierungen und empfohlene Plasmaspiegelbereiche Tagesdosis (mg) empfohlener Plasmaspiegel Wirkstoffe minimale mittlere maximale (ng/ml) Nichtselektive Monoamin-Rückaufnahme-Inhibitoren (NSMRI) Amitriptylin Amitriptylinoxid Clomipramin Desipramin Dibenzepin Doxepin Imipramin Lofepramin Maprotilin Nortriptylin Trimipramin Generation (Beispiel gekürzt). Selektive Serotonin-Rückaufnahme-Inhibitoren (SSRI) (Beispiel gekürzt). Neue Noradrenalin- und Serotonin-Rückaufnahme-Inhibitoren (Beispiel gekürzt). Reversible Inhibitoren der MAO-A (RIMA) (Beispiel gekürzt). Phytopharmaka (Beispiel gekürzt).

114 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO0HGLNDPHQW VH7KHUDSLH EHUVLFKW $XVJHZlKOWZHJHQGHU EHUVLFKWOLFKHQ'DUVWHOOXQJGHU'RVLVGHUZLFKWLJVWHQ:LUNXQJHQ 1HEHQZLUNXQJHQXQG'RVLVNRVWHQ Algorithm Annotations (cont) Major Depression in Adults for Mental Health Care Providers ANTIDEPRESSANTS: SSRIs, TCAs AND OHTERS (CONTINUED) TRICYCLICS SECONDARY AMINES Drug Name Starting Dose (range) Common Side Effects Amoxapine 25 mg 50 mg 100 mg 150 mg Desipramine 25 mg Dry mouth, blurred (Norpramin) 50 mg vision, constipation 75 mg 100 mg ( mg / day) Nortriptyline (Pamelor, Aventyl) Protriptyline (Vivactil) TETRACYCLICS Maprotiline 25 mg 50 mg 75 mg ( mg / day) 5 mg 10 mg (10-60 mg / day) 25 mg 50 mg 75 mg * Available as brand name only ** Prices obtained from 2000 Drug Topics red Book. Dry mouth, blurred vision, constipation Dry mouth, blurred vision, constipation Predominant Effects Antidepressant Antidepressant Antidepressant Special Considerations One of the least sedating and least anticholinergic of the tricyclics One of the least likely to cause orthostatic hypotension of tricyclics Least sedating tricyclic. May cause insomnia. Cost (AWP)** 25 mg (0.61) 50 mg (0.99) 100 mg (1.67) 150 mg (2.63) 25 mg (0.28) 50 mg (0.59) 75 mg (0.72) 100 mg (1.07) 25 mg (0.80) 50 mg (1.51) 75 mg (2.35) 5 mg (0.44) 10 mg (0.63) 25 mg (0.48) 50 mg (0.70) 75 mg (0.88)

115 à à à à à /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO0HGLNDWLRQV EHUVLFKW $XVJHZlKOWZHJHQGHU EHUVLFKWOLFKHQ'DUVWHOOXQJGHUZLFKWLJVWHQ.HQQGDWHQ]XU7KHUDSLH HLQVFKOLH OLFKGHU'RVLHUXQJVIRUPHQ ANTIDEPRESSANT MEDICATION TABLE Refer to pharmaceutical manufacturer s literature for full prescribing information à SEROTONIN SELECTIVE REUPTAKE INHIBITORS (SSRIs) à GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY Citalopram Celexa 20 mg 60 mg Reduce dose for No serious systemic Nausea, insomnia, Fluoxetine Prozac 20 mg 80 mg the elderly & toxicity even after sedation, headache, AM daily Paraxetine Paxil 20 mg 50 mg those with renal substantial overdose. fatigue dizziness, Response dosing. Can be Sertraline Zoloft 50 mg 200 mg or hepatic failure Drug interactions sexual dysfunction, rate = 2 started at an may include tricyclic anorexia, weight 4 weeks effective dose First Line Antidepressant Medication antidepressants, loss, sweating, GI immediately. Drugs of this class differ substantially in safety, tolerability and simplicity when used in carbarmazepine & distress, tremor, patients on other medications. Can work in TCA nonresponders. Useful in several anxiety warfarin. restlessness, disorders. Taper gradually when discontinuing these medications. Fluoxetine has the longer agitation, anxiety. half-life. SEROTONIN AND NOREPHINEPHRINE REUPTAKE INHIBITORS (SNRIs) GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY Venlafaxine Effexor IR 75 mg 375 mg Information Not IR Available Venlafaxine Effexor XR 75 mg 375 mg XR Dual action drug that predominantly acts like a Serotonin Reuptake inhibitor at low doses and adds the effect of an Norephinephrine Selective Reuptake Inhibitors at high doses. Possible efficacy in cases not responsive to TCAs or SSRIs. Taper dose prior to discontinuation. No serious systemic toxicity. Downtaper slowly to prevent clinically significant withdrawal syndrome. Few drug interactions. Comparable to SSRIs at low dose. Nausea, dry mouth, insomnia, somnolence, dizziness, anxiety, abnormal ejaculation, headache, asthenia, sweating. Response rate = 2 4 weeks ( 4 7 days at 300 mg /day) BID or TID dosing with IR. Daily dosing with XR. Can be started at an effective dose (75mg) immediately. à SEROTONIN (5-H2A) RECEPTOR ANTAGONIST and WEAK SEROTONIN REUPTAKE INHIBITORS GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICIT Y Nefazodone Serzone 200 mg 600 mg Trazodone Desyrel 150 mg 600 mg Corrects sleep disturbance and reduces anxiety in about one week. Reduce dose for the elderly & those with renal or hepatic failure No serious systemic toxicity from OD. Can interact with agents that decrease arousal/ impair cognitive performance and interact with adrenergic agents that regulate blood pressure. Somnolence dizziness, fatigue, dry mouth, nausea, headache, constipation, impaired vision. Unlikely to cause sexual dysfunction. Response rate = 2 4 weeks BID dosing. Requires dose titration. DOPAMINE and NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIs) GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY Bupropion -IR Wellbutrin - IR 200 mg 450 mg Bupropion - Wellbutrin - SR 150 mg 400 mg SR Reduce dose for the elderly & those with renal or hepatic failure Least likely antidepressant to result in a pt becoming manic. Do not use if there is a history of seizure disorder, head trauma, bulimia or anorexia. Can work in TCA nonresponders. Seizure risk at doses higher than max. Drug /drug interactions uncommon. Rarely causes sexual dysfunction. Response rate = 2 4 weeks BID / TID dosing. Requires dose titration. TRICYCLIC ANTIDEPRESSANTS (TCAs) Mainly Serotonin Reuptake Inhibitors GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY FFICACY SIMPLICITY Amitriptyline* Elavil, Endep* mg 300 mg Reduce dose for Imipramine* Tofranil* 75 mg 300 mg those with renal or Doxepin* Sinequan* 75 mg 300 mg hepatic failure These antidepressants are not recommended for use in the elderly. Highest response rates. TATCAs useful in chronic pain, migraine headaches & insomnia. * Tertiary Amine Tricyclic Antidepressants (TATCAs). Serious toxicity can result from OD. Slow system clearance. Can cause multiple drug/ drug interactions. Sedation, increased anticholinergic effects, orthostatic hypo-tension, cardiac conduction disturbances, arrhythmia & wt gain, dizziness, sexual dysfunction. Response rate = 2 4 weeks Therapeutic Levels: Imipramine ng/ml Can be given QD. Monitor serum level after one week of treatment. TRICYCLIC ANTIDEPRESSANTS (TCAs) Mainly Norepinephrine Reuptake Inhibitors GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILIT Y Desipramine * Norpramin* mg 300 mg Nortriptyline Aventy/Pamelor 50 mg 150 mg Reduce dose for the elderly & those with renal or hepatic failure Consider Desipramine or Nortriptyline first in the elderly if TCAs are necessary. * Secondary Amine Tricyclic Antidepressants (SATCAs) Serious toxicity can result from OD. Reserve Maprotiline as a second-line agent due to risk of seizures at therapeutic & nontherapeutic doses. Generally Good. EFFICACY Response rate = 2 4 weeks Therapeutic Levels: Desipramine ng/ml Nortriptyline ng/ml SIMPLICITY Can be given QD. Can start effective dose immediately. Monitor serum level after one week of treatment.

116 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO$U]QHLPLWWHOLQWHUDNWLRQHQ $XVJHZlKOWZHJHQGHU EHUVLFKWOLFKHQ'DUVWHOOXQJGHU,QWHUDNWLRQVPHFKDQLVPHQ Table B. Dual Mechanism Antidepressant Drug Interactions a-c PRECIPITANT OBJEKT DESCRIPTION DRUG DRUG Bupropion Carbamazepine The plasma concentration of bupropion may decrease. Although this interaction is not well documented, it would be prudent to monitor for altered bupropion response if CBZ is initiated, discontinued, or changed in dosage Bupropion Valproic acid Bupropion may increase serum valproic acid levels Bupropion Levodopa A higher incidence of adverse experiences occurs with concurrent use of these agents. Use small initial doses and small gradual dose increments of bupropion Nefazodone Benzodiazepines Substantial and clinically import increases in plasma concentrations of alprazolam and triazolam have occurred. initial dose of alprazolam by 50 %, initial dose of triazolam by 75 % when coadministered with nefazodone. Lorazepan was not affected Nefazodone Haloperidol Haloperidol clearance was decreased by 35 % with no significant increase in peak plasma concentrations or time to peak Nefazodone Pimozide Plasma levels of pimozide may be increased, resulting in QT prolongation or torsades des pointes, sometimes fatal. Do not use concurrently Bupropion MAOIs Refer to Appendix 9a for drug interaction and for washout period Nefazodone Venlafaxine Mirtazapine Nefazodone Cisapride d Plasma levels of cisapride, may be increased, resulting in QT prolongation or torsades de pointes, sometimes fatal. Do not use concurrently. Nefazodone Digoxin C max 9 C min and AUC of digoxin were increased by 29 %, 27 %, and 15 % respectively in one study. Monitor digoxin levels Nefazodone Simvastatin, Lovastatin Case reports of resultant myositis and rhabdomyolysis when nefazodone added to simvastatin or lovastatin Nefazodone Propranolol propranolol concentration. in m-cpp metabolite of nefazodone. No initial changes in drug dosage necessary; any future changes should be based on clinical response Nefazodone Cyclosporine, May inhibit the metabolism of tacrolismus or cyclosporine Tacrolimus a Drug Facts and Comparisons by Facts and Comparisons, St. Louis, Missouri b Hansen and Horns Drug Interactions Analysis and Management. Hansten PD, Horn JR eds.; 1999 by Facts and Comparisons, St. Louis, Missouri c List is not be all inclusive d Cisapride was recently withdrawn from the market although it will still be available to select patients trough manufacturers patient enrollment program

117 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO7KHUDSLHNRQWUROOH $XVJHZlKOWZHLOKLHUGLHZHVHQWOLFKHQGHULP9HUODXIGHU3KDUPDNRWKHUDSLH GXUFK]XI KUHQGHQ0D QDKPHQGDUJHVWHOOWZHUGHQ Tabelle 7: Klinische und Laboruntersuchungen als Voraussetzung für eine sichere Pharmakotherapie Vor Beginn der Akutbehandlung 1. Bei NSMRI Allgemeine körperliche Untersuchung, orientierende neurologische Untersuchung, RR, Leber- und Nierenfunktion, Differentialblutbild, u. U. insbesondere bei älteren Patienten EKG 2. Bei Mianserin wie 1., Normwerte der Leukozyten sind Voraussetzung für einen Therapiebeginn 3. Bei Viloxazin, Trazodon, SSRI, MAO-Inhibitoren wie 1. Im Therapieverlauf: Empfohlen werden: 14tägige Kontrollen von Blutbild und Leberwerten während der ersten drei Monate; sie sind (außer bei Mianserin) nicht obligat. Im übrigen richtet sich das Vorgehen individuell nach den beim jeweiligen Patienten vorliegenden Ausgangswerten und Vorerkrankungen (z. B. EKG). Bei Verdacht auf Non-Compliance bzw. Therapieresistenz Blutspiegelbestimmung. Bei Lithiumbehandlung: Zu Beginn: wie 1., zusätzlich Schilddrüsenhormone (T 4, TSH basal). Während der Einstellphase wöchentliche Li-Serumspiegelkontrollen. Im Verlauf: Li-Spiegelkontrollen alle 4 12 Wochen, bei allen Zuständen, die den Wasser- und Elektrolythaushalt verändern und bei UAW- bzw. Intoxikationsverdacht (verstärkter Tremor, Ataxie, Durchfall, Erbrechen, Bewußtseinsstörungen). Bei allen Konsultationen klinische Untersuchung auf euthyreote Struma (Halsumfang etc.) und Hypothyreosezeichen. Kreatininbestimmung und Schilddrüsenparameter sowie orientierender Harnstatus alle 6 12 Monate. %HLVSLHO6WXIHQVFKHPDEHL1RQ5HVSRQGHUQ //&3$>6@ $XVJHZlKOWZHJHQGHUDEJHVWXIWHQ EHUVLFKWOLFKHQ9RUJDEHQ(LQH$EELOGXQJLQ)RUPHLQHV 6WXIHQGLDJUDPPVZlUHZ QVFKHQVZHUW Recommendations for Managing Nonresponse to an Antidepressant (see Table 4.6) Once an antidepressant is selected, an initial improvement (at least 20% reduction in depression scores) should be seen within 3 to 4 weeks. Otherwise, the following interventions are indicated: First-line treatments Second-line treatments Third-line treatments Not recommended 2SWLPL]HWKHDQWLGHSUHVVDQWE\LQFUHDVLQJWKHGRVHDVWROHUDWHG/HYHOHYLGHQFH 6ZLWFKWRDQDQWLGHSUHVVDQWZLWKDGLIIHUHQWQHXURFKHPLFDODFWLRQ/HYHO evidence). $XJPHQWZLWKOLWKLXPRUWULLRGRWK\URQLQHT3) (Level 1 evidence). 6ZLWFKWRDQDQWLGHSUHVVDQWZLWKDVLPLODUQHXURFKHPLFDODFWLRQ/HYHOHYLGHQFH $XJPHQWZLWKEXVSLURQHRUDQDW\SLFDODQWLSV\FKRWLFVXFKDVRODQ]DSLQH/HYHO evidence). &RPELQHZLWKDQRWKHUDQWLdepressant (Level 3 evidence). $XJPHQWZLWKSLQGRORO/HYHOHYLGHQFH

118 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO(UKDOWXQJVWKHUDSLH $XVJHZlKOWZHJHQGHUULVLNRDGDSWLHUWHQhEHUVLFKW]XP/DQJ]HLWPDQDJHPHQWXQG9RUJHKHQ ]XU%HHQGLJXQJ: QVFKHQVZHUWZlUHHLQ9HUZHLVDXIVXEVWDQ]JUXSSHQDGDSWLHUWH (PSIHKOXQJHQ Recommendations for Maintenance Pharmacotherapy (see Table 4.6) All patients should be maintained on antidepressants for at least 6 months after clinical remission (Level 1 evidence). Patients with the following risk factors should be maintained on antidepressants for at least 2 years: older age, psychotic features, chronic episodes, recurrent episodes (3 or more life time), frequent episodes (2 or more in 5 years), difficultto-treat episodes, and severe episodes (Level 2 evidence). The antidepressant dosage in the maintenance phase should be the same as in the acute phase (Level 2 evidence). Antidepressants should be tapered slowly to avoid discontinuation symptoms (Level 3 evidence). %HLVSLHO(PSIHKOXQJHQ]XP:HFKVHOGHU$QWLGHSUHVVLYD //&3$>6@ $XVJHZlKOWZHJHQGHUXPIDQJUHLFKHQ,QIRUPDWLRQHQXQG+LQZHLVH]XU9HUPHLGXQJYRQ,QWHUDNWLRQHQEHLP:HFKVHOYRQ$QWLGHSUHVVLYD(LQH EHUVLFKWOLFKHUHJUDSKLVFKH'DUVWHOOXQJ ZlUHZ QVFKHQVZHUW Table 4.5 Washout recommendations for switching antidepressants Switching from Switching to SSRI Novel (mixed action) TCA RIMA MAOI SSRI No washout No washout No washout 1 week 1 week Citalopram Be aware of additive Be aware of additive Be aware that SSRIs can Some data indicate (5 weeks Fluoxetine serotonergic effects for up serotonergic effects for up increase serum TCA that an SSRI and RIMA for fluxe- Fluvoxamine to 1 week after stopping to 1 week after stopping levels for up to 1 week can be safely combined, tine) Paroxetine SSRI SSRI after stopping SSRI but this requires Sertraline (5 weeks for fluoxetine) (5 weeks for fluoxetine) specialist input. Novel (mixed action) No washout No washout No washout 3 5 days 1 week antidepressants Venlafaxine should be TCA should be started at No washout with Bupropion SR started at a lower dose to a lower dose to avoid burping Mirtazapine avoid additive additive noradrenergic Nefazodone noradrenergic effects effects Trazodone Bupropion should be Venlafaxine Venlafaxine XR started at a lower dose to avoid additive norardrenergic effects TCA No washout No washout No washout No washout 1 week Amitriptyline Be aware that SSRI can Venlafaxine should be Desipramine increase serum levels of started at a lower dose to Imipramine TCAs for up to 1 week avoid additive Nortriptyline after stopping TCA. noradrenergic effects and others Be aware of additive Bupropion should be serotonergic effects when started at a lower dose to switching from avoid additive clomipramine to SSRIs. noradrenergic effects RIMA Moclobemide 3 days 3 days 3 days Not applicable 3 days MAOI Phenelzine 2 weeks 2 weeks 2 weeks 2 weeks 2 weeks Tranylcypromine SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant; RIMA = reversible inhibitor of MAO-A; MAOI = monoamine oxidase inhibitor.

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120 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHOhEHUVLFKW]XDQGHUHQVHOWHQHQ7KHUDSLHQ $XVJHZlKOWZHJHQGHU EHUVLFKWOLFKHQ'DUVWHOOXQJDNWXHOOGLVNXWLHUWHUDEHUVHOWHQHU 7KHUDSLHIRUPHQ Recommendations for Other Biological Treatments (see Table 4.6).. Sleep deprivation is an effective transient treatment for depressive disorders (Level 2 evidence). Response may be maintained using medications (for example, antidepressants, lithium, or pindolol) or bright light (Level 2 evidence). Sleep deprivation may be most useful as an adjunctive treatment in hospitalized patients. Exercise alone may be effective in patients with mild depression (Level 2 evidence) and can be used as an adjunctive treatment to first-line treatments (Level 3 evidence). Limbic surgery (psychosurgery) has limited evidence for efficacy but may be considered for the most refractory and chronic cases (Level 3 evidence). Transcranial magnetic stimulation (TMS) and vagus nerve stimulation (VNS) are promising new biological treatments, but there is too little evidence to warrant recommendations for general clinical use (Level 2 and 3 evidence). %HLVSLHO,QGLNDWLRQVVWHOOXQJ //&3$>6@ $XVJHZlKOWZHJHQSUlJQDQWHU1HQQXQJYRQZHVHQWOLFKHQ,QGLNDWLRQHQXQWHU9HUZHLVDXI 1HEHQZLUNXQJHQ Recommendations for Electroconvulsive Therapy (see Table 4.6) Electroconvulsive therapy (ECT) is an effective treatment for major depressive disorder (MDD) (Level 1 evidence). Indications for ECT include acute suicidal risk, severe physical deterioration, psychotic features, refractoriness to medications, and patient preference. Unilateral electrode placement requires suprathreshold doses of ECT (Level 2 evidence). Side effects of ECT are generally mild, with evidence for a transient, short- term memory disturbance (Level 2 evidence). Recommendations for Light Therapy (see Table 4.6) Light therapy is an effective treatment for recurrent major depressive disorder (MDD) with a seasonal pattern, of mild- to-moderate severity (Level 1 evidence). An adequate trial of light therapy should be 2 to 4 weeks of lux fluorescent light for 30 minutes daily, in the early morning (Level 2 evidence). Patients usually need to continue daily light therapy through out the winter and can discontinue treatment in the summer (Level 3 evidence). There is insufficient evidence regarding the efficacy of light therapy for long-term or maintenance use.

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125 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO3UlYHQWLRQYRQ7KHUDSLHNRPSOLNDWLRQHQ $XVJHZlKOWZHJHQGHUDXVI KUOLFKHQ/LVWHYRQH[SOL]LWHQ:DUQKLQZHLVHQGLHYRU$QZHQGXQJ GHU7KHUDSLH]XEHDFKWHQVLQG,QGHU/HLWOLQLHZLUGDXIGLHQRWZHQGLJH'LDJQRVWLNYHUZLHVHQ Management of Major Depressive Disorder in Adults Appendix 8. Electro-convulsive Therapy Contraindications Or Conditions Associates With Increased Risk In ECT Contraindication - Space occupying cerebral lesion or other condition resulting in elevated intracranial pressure confers added risk of brainstem herniation. Caution - Significant cardiovascular problems such as recent myocardial infarction, severe cardiac ischemic disease or profound hypertensive illness (whatever the cause). Simultaneous stimulation of both the sympathetic and parasympathetic systems result in changes in cardiac output and heart rate in the ictal and immediate post ECT period, causing added risk of transient arrhythmias, cardiac ischemia and profound hypertension, conferring greater health risk in susceptible individuals. Caution - Recent intracerebral hemorrhage, or patients with bleeding or unstable vascular aneurysms or malformations. Caution - Degenerative diseases of the axial or appendicular skeleton use of anesthetic and muscle relaxant techniques have added to the safety profile of ECT in these individuals. Patient currently taking monoamine oxidase inhibitor medication (MAOi). Ideally, MAOi s should be discontinued two weeks prior to initiating ECT in order to prevent threatening hypertensive changes during treatment as described above. Caution Patient currently taking lithium. May result in neurotoxic syndrome marked by increased mental confusion, disorientation and unresponsiveness. High Anesthesia risk American Society of Anesthesiologists level 4 or 5. The basic pre-ect workup may be varied, but should generally reflect those concerns presented above. The basic components of the pre-ect evaluation involve: 1. Complete diagnostic history, mental status examination, and physical examination 2. Review of the patients past and current medical illnesses and treatments rendered 3. Formulation of a patient-specific risk-benefit inventory with comparison of ECT to other forms of treatment 4. Determination of the setting of ECT administration (inpatient versus outpatient) 5. If ECT is indicated, obtaining written consent from the patient after reviewing the benefits and risks or ECT, along with an explanation detailing other available therapeutic options 6. Initiating a medical workup as necessary in order to further assess and minimize risk to the patient 7. Anesthesia evaluation. As a general guideline, the following studies may be considered, time permitting: Complete blood count Serum electrolytes Electrocardiogram CNS imaging - consider especially if there is suggestion of presence of aforementioned CNS pathology. May appear in the form of CT or MRI, usually within the past year Baseline clinical assessment of cognitive functioning Spinal x-ray - Not generally recommended, but consider especially in cases where there is a history of musculoskeletal symptoms or disease Urinalysis Blood urea nitrogen and creatinine Chest x-ray (PA and lateral) Other testing where necessary.

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130 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO6FKXOXQJVLQKDOWH]LHOH $XVJHZlKOWZHJHQGHUNXU]HQ EHUVLFKWOLFKHQ'DUVWHOOXQJGHU/HUQLQKDOWHXQG+LQZHLVHQ]XU GLGDNWLVFKHQ8PVHW]XQJXQG]LHOJUXSSHQJHUHFKWHU9HUZHLVDXIZHLWHUI KUHQGH,QIRUPDWLRQ Initial Interventions Education Education is an important component of the management of any Major Depressive Disorder and especially valuable in clarifying the person s uncertainty and misconceptions. The information provided will allow most people to gain greater control over their disorder and be able to recognise actions they can take, and when they need additional assistance from a healthcare worker. Where appropriate, and with the individual s permission, family members should also receive information that will help them to provide support through the treatment period and enable them to act appropriately should there be any relapse. Education should be provided in short five minute sessions over a number of appointments and should be tailored to the individual's level of understanding and culture. Handouts and information pamphlets are particularly helpful. The following information is important: - Major Depressive Disorder is not a weakness or a character defect. - Recovery is the rule not the exception. - Treatment is effective and there are many treatment options available. There is a suitable treatment for almost every person. - The goal of treatment is to get well (100%) and be better placed to cope with emotional problems in the future. - The rate of recurrence is quite high: 50% of people who have had one episode of Major Depressive Disorder will relapse, 70% of people who have had two episodes will relapse, and 90% of people who have had three episodes will relapse. Therefore continuation with treatment to avoid relapse is important. - The individual and their family can be taught to recognise early warning signs of Major Depressive Disorder. - By seeking early treatment after recognising these warning signs, the severity of the episode may be greatly reduced. There are also a number of self-help books available that provide useful information about depression and strategies for both the person with depression and their friends and families for coping with it. These are available through public libraries and general book stores. Some examples of books include: The Silver Lining: How to Conquer Depression. A NZ Perspective (1989), by Margaret Mourant. (Published by William Collins, Auckland). This book includes a chapter on how other people can help the depressed person. The Depression Workbook (1992), by Mary-Anne Copeland. (New Harbinger). This book includes information for people with Bipolar Mood Disorder. I Can See Tomorrow (1995), by Patricia Owen. This can be purchased from book stores for around $29.95, and is also available through Tandem Press (PO Box Birkenhead, Auckland, Ph ). Sharing the Load (1996), by Gwendoline Smith. (Published by Random House).

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139 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO.RVWHQ1XW]HQ5HFKQXQJDP%HLVSLHOYRQ7KHUDSLHNRVWHQ $XVJHZlKOWZHJHQGHUDXVI KUOLFKHQJHVXQGKHLWV NRQRPLVFKHQ%HWUDFKWXQJ=XJUXQGHOLHJW HLQH0RGHOOUHFKQXQJLQGHUWUL]\NOLVFKH665,VXQG/RIHSUDPLQYHUJOLFKHQZHUGHQ Economics of Antidepressants Recommendations: As they represent the most cost-effective option, tricyclic antidepressants should be used as the routine first line drug treatment for depression in primary care (C) The choice of antidepressant should be based on individual patient factors; these would include (D) the desirability or otherwise of sedation or other effects associated with a particular drug; previous response to a particular drug; co-morbid psychiatric or medical conditions; concurrent drug therapy. If the toxic effects of the older tricyclic antidepressants are perceived to be a problem, for example in a patient who has previously taken a drug overdose, then lofepramine is a more cost effective choice than an SSRI (C) A general policy of switching from tricyclics to SSRIs does not appear cost-effective. Where the toxic effects of tricyclic antidepressants give cause for concern, substitution with lofepramine appears relatively cost-effective.... Conservative scenario Assumptions: Accidental fatal poisonings associated with a single-ingested tricyclic antidepressant will reduce proportionately as tricyclic use is reduced (low estimate, Table 4). All hospitalisations attributed to the toxic effects of antidepressants will reduce proportionately as tricyclic use is reduced (low estimate, Table 4). Differences in efficacy and dropout between antidepressants are insignificant (or approximately cancel one another in consequences to patients) leading to no net change in primary care, outpatient use or inpatient psychiatric services as a result of antidepressant choice (Figures 4 and 6). For every patient year of treatment changed: Optimistic scenario A Cost of SSRI1 average cost of SSRI/year ( ) 282 B Cost of Lofepramine 1 average cost of lofepramine/year ( ) 101 C Cost of Tricyclic 1,2 average cost of tricyclic/year ( ) 45 D Cost of toxicity admission 3 35,140 bed days x 160 per day / 528,700 ( ) 11 E A-(C+D) SSRI net cost/patient (D ) 226 F B-(C+D) Lofepramine net cost/patient (D ) 45 G Lives saved (SSRI) (DLS) H Lives saved (lofepramine) (DLS) E/G Incremental cost per life saved switching to an SSRI from an older (D /DLS) 2,500,000 tricyclic F/H Incremental cost per life saved switching to lofepramine from an older (D /DLS) 520,000 tricyclic (E-F)/(G-H) Incremental cost per life saved switching to an SSRI from lofepramine (D /DLS) 60,000,000 1 At WHO Defined Daily Dose 2 Average yearly cost of a tricyclic or related antidepressant excluding lofepramine 3 Based on average cost per inpatient week in Scotland 1995/96 (Scottish Health Service Costs, 1996) 4 Differences in fatality association rates between SSRIs and lofepramine are not statistically significantly different

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142 /HLWOLQLHQEHULFKW'HSUHVVLRQ %HLVSLHO0RQLWRULQJGHU/HLWOLQLHQ$QZHQGXQJ $XVJHZlKOWZHJHQGHU/HLWOLQLHQVSH]LILVFKHQ9RUJDEHQ]XU0HVVXQJGHU3UR]HVVTXDOLWlW Measurement Specifications Possible Success Measure #1a Percentage of patients with major depression with documentation of multi axial DSM-IV evaluation. Population Definition Adults greater than 18 years of age with depression Data of Interest # of patients with major depression with documentation of multi axial DSM-IV evaluation. # of patients with a diagnosis of depression Numerator/Denominator Definitions Numerator: documentation of multi axial evaluation process including all 5 axes. Denominator: Patients with current ICD-9 code, such as 296.2x or 296.3x for depression Method/Source of Data Collection Each mental health unit may generate a list of patients meeting inclusion criteria than 18 years of age, and current ICD-9 depression code. The same list may be used for measures 1a and 1b and measures 2a and 2b. A random sample of 10 cases per month may be selected for review. Documentation of multiaxial assessment is considered to be yes when documentation of all 5 domains (including Axis 1, clinical disorders; Axis 2, personality disorders; Axis 3, general medical conditions; Axis 4, psychosocial and environmental problems; and axis 5, global assessment functioning) is found. Time Frame Pertaining to Data Collection Randomly selected cases may be reviewed monthly. %HLVSLHO'RNXPHQWDWLRQVYHUIDKUHQ //,&6,PHQWDOKHDOWK>6@ $XVJHZlKOWZHJHQ EHUVLFKWOLFKHQ9RUJDEHGHU(QWVFKHLGXQJVNULWHULHQ Depression in Specialty Care Patient population: Patients seen during the target month with an ICD-9 code for depression, such as 296.2x or 296.3x Decision criteria Measure #1a: Documentation of multiaxial assessment is YES when you find documentation of ALL 5 domains: Axis 1: Clinical Disorders, Axis 2: Personality disorders, Axis 3: general Medical conditions, Axis 4: Psychosocial and Environmental problems, AND Axis 5: global Assessment of Functioning. See algorithm annotation 2. Decision criteria Measure #1b: Documentation of symptoms is YES when you find documentation of ALL 5 DSM I-symptoms (depressed mood, loss of interest or pleasure, weight loss, insomnia, agitation or retardation, fatigue, feelings or worthlessness or guilt, diminished concentration, recurrent thoughts of death or suicide) AND least one of the symptoms is either depressed mood or loss of interest pleasure. See algorithm annotation 2. Data Collection Worksheet #1a Multiaxial diagnosis made? #1b Symptom Assessment Case # Circle Axis evaluated Check of all 5= Yes # symptoms documented Check if 5 or more total # of checks Total # of checks

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216 Die Titel der ÄZQ Schriftenreihe Projekte ÄZQ Schriftenreihe Band 10 Leitlinien-Clearingbericht Koronare Herzkrankheit ÄZQ Schriftenreihe Band Seiten, Paperback ISBN ,90 Die ÄZQ Schriftenreihe ab Band 10 erscheint in der Edition Medizinische Schriften. Die Auslieferung erfolgt über den Buchhandel oder direkt ab Verlag. Im Internet unter: MediComBooks.de 170 Seiten, Paperback ISBN ,90 MediComBooks Medical Communication & Books MediComBooks.de Edition Medizinische Schriften Informationen und Arbeitsmaterialien öffentlicher Einrichtungen, Institutionen und Gesellschaften Lieferbare Titel im Zuckschwerdt Verlag Leitlinien-Clearingbericht Asthma bronchiale Band 9 Leitlinien-Clearingbericht Diabetes mellitus Typ 2 Band Seiten, Paperback ISBN , Seiten, Paperback ISBN ,90 Leitlinien-Clearingbericht Akuter Rückenschmerz Band 7 Leitlinien-Clearingbericht Schmerztherapie bei Tumorpatienten Band Seiten, Paperback ISBN , Seiten, Paperback ISBN ,90 Leitlinien-Clearingbericht Hypertonie Band Seiten, Paperback ISBN ,20 Die Leitlinien-Clearingberichte Band 5 bis Band 9 sind erschienen im W. Zuckschwerdt Verlag GmbH, Germering Der Bezug erfolgt über den Buchhandel.

217 ISSN I SBN Schriftenreihe