The recommendations that follow are those from the guideline's executive summary; detailed recommendations can be found in the original guideline document. Each recommendation is rated based on the level of the evidence and the grades of recommendation. Definitions of the grades of the recommendations (A, B, C, Good Practice Points) and level of the evidence (Level I-Level IV) are presented at the end of the "Major Recommendations" field.
C - The basic assessment of depression includes the history, the mental state examination, and physical examination.
- Take a detailed history of the presenting symptoms and determine the severity and duration of the depressive episode. Establish history of prior episodes, prior manic or hypomanic episodes, substance abuse, and other psychiatric illnesses. Look out for coexisting medical conditions. Check for family history of mental illness, depression, and suicide. Establish the personal history and the available supports and resources. Evaluate functional impairment and determine life events and stressors.
- Do a mental state examination. This includes an evaluation of the severity of symptoms and assessment for psychotic symptoms. All assessments of depression will include an assessment of the risk of suicide, self-harm, and risk of harm to others. (See Annex II on page 32 in the original guideline document.)
- Do a physical examination to exclude a medical or surgical condition.
- Laboratory testing may be indicated if there is a need to rule out medical conditions that may cause similar symptoms.
(Grade C, Level IV)
C - Referrals to a psychiatrist are warranted when
- there are comorbid medical conditions for which expertise is required regarding drug-drug interactions
- there is diagnostic difficulty
- one or two trials of medication have failed
- if augmentation or combination therapy is needed
- for those with comorbid substance abuse or severe psychosocial problems
- the patient is pregnant or plans to become pregnant
- for postnatal depression
- if specialized treatment like electroconvulsive therapy is indicated but unavailable in the primary care setting
(Grade C, Level IV)
C - Once an antidepressant has been selected, start with a low dose and titrate to the full therapeutic dose gradually, while assessing patients mental state and watching for the development of side-effects. The frequency of monitoring will depend on the severity of the depression, suicide risk, the patient’s cooperation, and the availability of social supports. (Grade C, Level IV)
B - All antidepressants, once started should be continued for at least 4 to 6 weeks. (Grade B, Level IIb)
C - If there is little or no improvement after switching, it is recommended that a psychiatric referral is sought for the following:
- Augment the first antidepressant with a second medication (Augmentation)
- Add a second antidepressant to the first (Combination)
(Grade C, Level IV)
GPP - At the end of the Continuation phase the antidepressant medication should be gradually tapered to avoid discontinuation symptoms. Patients should be followed up during the next few months to ensure that a new depressive episode does not occur. If recurrence occurs, the patient is likely to respond to the same antidepressant at the same dosage that was effective previously, which should then be continued for 6 months. (GPP)
A - Psychotherapy alone is as efficacious as antidepressant medication in patients with mild to moderate major depression and can be used as first-line treatment. (Grade A, Level Ia)
A - Cognitive Behaviour Therapy is also an effective maintenance treatment and is recommended for patients with recurrent depression who are no longer on medication. (Grade A, Level Ia)
A -Concurrent combined psychotherapy and pharmacotherapy is recommended in severe depression and chronic depression as it is more effective than either alone in these conditions. (Grade A, Level Ib)
B - Electroconvulsive therapy may be considered as the first-line treatment for patients with severe depression, depression with psychotic features, marked functional impairment, catatonic stupor, high suicide risk, or food refusal leading to nutritional compromise. It is also considered in any other situation when a particularly rapid antidepressant response is required, such as in pregnancy and in those with comorbid medical conditions that preclude the use of antidepressant medications. (Grade B, Level IIb)
Definitions:
Grades of Recommendations
Grade A (evidence levels Ia, Ib) Requires at least one randomised controlled trial, as part of the body of literature of overall good quality and consistency addressing the specific recommendation
Grade B (evidence levels IIa, IIb, III) Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation
Grade C (evidence level IV) Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates absence of directly applicable clinical studies of good quality.
Good Practice Points Recommended best practice based on the clinical experience of the guideline development group
Levels of Evidence
Level Ia Evidence obtained from meta-analysis of randomised controlled trials
Level Ib Evidence obtained from at least one randomised controlled trial
Level IIa Evidence obtained from at least one well-designed controlled study without randomisation
Level IIb Evidence obtained from at least one other type of well-designed quasi-experimental study
Level III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies
Level IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities
