Depression Guidelines

Updated: Oct 07, 2019
  • Author: Jerry L Halverson, MD; Chief Editor: David Bienenfeld, MD  more...
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Guidelines

Guidelines Summary

French Association for Biological Psychiatry and Neuropsychopharmacology and the Fondation FondaMental

Clinical guidelines on the management of depression in patients with psychiatric comorbidities were published in January 2019 by the French Association for Biological Psychiatry and Neuropsychopharmacology and the Fondation FondaMental. [218]

Comorbid anxiety disorders

The following are recommended first-intention strategies during the first episode of major depressive disorder (MDD) with comorbid anxiety disorder:

  • Concurrent treatment of both disorders
  • Use of the same therapist, to the greatest extent possible, for disease management, with treatment including cognitive behavioral therapy, as well as a closer follow-up

First-intention medications and other treatment for MDD with comorbid obsessive-compulsive disorder, panic disorder, social anxiety, generalized anxiety disorder, or posttraumatic stress disorder include the following:

  • Selective serotonin reuptake inhibitor (SSRI)
  • Serotonin and norepinephrine reuptake inhibitor (SNRI)
  • Psychotherapy in combination

Comorbid substance use disorders

The following are recommended in first-intention treatment during the first episode of MDD with comorbid substance use disorder:

  • Full-time hospitalization or
  • Close monitoring in consultation (at least weekly)
  • Electrocardiographic evaluation prior to treatment
  • Substitution treatment initiated in response to opioid dependence

Also consider the following in first-intention treatment of patients with severe alcohol addiction:

  • Close biologic monitoring - Complete blood count, blood electrolytes, liver and renal function
  • Treatment of physical withdrawal syndrome
  • Antidepressant treatment - Prescribed after reassessment of mood and once appropriate care for physical withdrawal syndrome has ended

First-intention medications and other treatments for MDD with comorbid substance use disorders include the following:

  • Severe substance use disorders (except alcohol and nicotine) - SSRI; SNRI; α2 antagonist; disease management involving a team specialized in addictology, psychoeducational groups, or psychotherapy focusing on addictive relapse prevention; concurrent treatment of MDD and addiction
  • Severe comorbid alcohol addiction - SSRI, SNRI, α2 antagonist, structured psychotherapy
  • Active smoking - SSRI, SNRI, α2 antagonist, structured psychotherapy, concurrent treatment of MDD and smoking cessation

Comorbid personality disorders

The following are recommended during the first episode of MDD with comorbid personality disorder:

  • First-intention treatment with SSRI or SNRI (as monotherapy or in combination with psychotherapy)
  • Second-intention treatment with an imipraminic antidepressant or α2 antagonist

Geriatric depressive disorder

In adults over age 65 years, it is recommended, during an episode of MDD, that a physical examination and laboratory studies be performed to identify medical problems that could exacerbate or mimic depressive symptoms. Assessment includes the following:

  • Clinical examination
  • Biologic checkup - Ie, complete blood count, blood electrolytes, liver and renal function, and thyroid-stimulating hormone
  • Electrocardiographic evaluation
  • Mini-Mental State Examination
  • Evaluation of clinical severity using clinician- and self-rated scales

First-intention treatments for geriatric depression include the following:

  • Mild to moderate depression - SSRI, α2 antagonist
  • Moderate to severe depression - SSRI, SNRI, α2 antagonist
  • Severe cognitive impairment - SSRI, SNRI
  • Severe psychomotor agitation - SSRI, α2 antagonist
  • Severe psychomotor retardation - SSRI, SNRI
  • Severe sleep disorders - SSRI, α2 antagonist
  • Severe anhedonia - SSRI, SNRI
  • Psychotic symptoms - SNRI, potentiation with an atypical antipsychotic
  • High suicide risk - SSRI, SNRI

International Society for Nutritional Psychiatry Research

The International Society for Nutritional Psychiatry Research (ISNPR) recommends omega-3 polyunsaturated fatty acids (PUFAs) as adjunctive therapy for major depressive disorder. [219] The recommended therapeutic dosage of pure eicosapentaenoic acid (EPA) is 1–2 g/day (either from pure EPA or a combination of EPA and docosahexaenoic acid [DHA]) for at least 8 weeks as adjunctive treatment. The guideline also endorses n-3 PUFAs as a potential prophylactic treatment for high-risk populations, and indicates that they can be used in overweight patients and those individuals with elevated levels of inflammatory markers.