Guidelines
Look for the following risk factors in patients with depression and monitor for development of depressive disorder:
Personal or family history of depression, bipolar disorder, suicide-related behavior, substance abuse, other psychiatric illness or significant psychosocial stressors.
Systematic monitoring should occur at least annually.
Assess for depression in adolescents at high risk or who present with emotional problems.
Base assessment on diagnostic criteria in DSM-IV or International Classification of Diseases, 10th Revision.
Use standardized depression tools for assessment:
Common presenting symptoms are insomnia, weight loss, drop in academic performance and family conflict.
Assess by interviews with patient and parents/ guardians and evaluation of functioning in school, home and peer domains:
Family involvement is crucial.
Co-morbidities include anxiety disorder, attention-deficit hyperactivity, bipolar disorder, abuse, substance abuse and trauma.
Initial management includes educating and counseling patient and family on depression and management options. Discuss confidentiality limits.
Develop treatment plan, including specific goals in key domains, with patients and family.
Management must include a safety plan, especially during initial treatment: restrict access to lethal means keeping possibility of suicide ideation and attempt high in mind.
For treatment of mild depression, consider active support and monitoring (6 – 8 weeks of weekly or biweekly visits), but offer antidepressant or psychotherapy for persistent symptoms.
For moderate or severe depression or complicating factors, consider referral to a psychiatrist:
Antidepressant or psychotherapy or crisis intervention is also recommended.
Use scientifically tested treatments, including cognitive behavioral therapy, interpersonal psychotherapy and antidepressant treatment, when appropriate, to achieve treatment goals.
Patients should be monitored for adverse events during antidepressant treatment:
US FDA recommends weekly face-to-face visits in the first 4 weeks; similar guidelines lack in India. Follow up visits are decided upon by patient’s condition.
Ongoing management includes systematic tracking of goals and outcomes viz functioning at home, school and peer setting domains and resolution of symptoms:
Patients should be seen within 1 week of starting treatment.
Depressive symptoms, suicide risk, adverse treatment effects, treatment adherence and stressors should be assessed at each visit.
Medication and monthly monitoring are recommended 6 to 12 months after depressive symptoms resolve.
Monitor for up to 2 years if depressive episode are recurring.
Highest relapse risk is in first 8 to 12 weeks after medication discontinuation.
If there is no improvement after 6 to 8 weeks of treatment, reassess diagnosis and initial treatment and consider referral to psychiatrist.
If all diagnostic and therapeutic approaches result in only partial improvement, consider referral to psychiatrist.