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Management Of Major Depressive Disorder

Acute Phase Treatment: Mild To Moderate

Major Depressive Disorder

The combination of antidepressant medication and psychotherapy may be the initial treatment approach for patients with moderate depression in the presence of psychosocial stressors, interpersonal difficulties, intra-psychic conflict, and personality disorders. Combination therapy may also be appropriate for patients with only partial remission on one type of treatment, or with a history of poor adherence to treatment. Most primary care physicians can medically manage these patients while referring them to a professional psychotherapist for co-management.

Assessing for Adequate Response in the Acute Phase

Overall, if after the initial 4 8 weeks there is not a moderate improvement in baseline symptoms in the acute phase, then a reassessment of the diagnosis, medication regimen and / or psychotherapy, adherence, substance or alcohol use is in order. Increasing the treatment dose is the first step to be considered. If 4 8 weeks after the increase of treatment dose there is not a moderate improvement in symptoms, another review should occur. Other treatment options should then be considered in consultation with a psychiatric specialist.

How Is Depression Syndrome Treated

Depression can be serious, but its also treatable. Treatment for depression includes:

  • Self-help: Regular exercise, getting enough sleep, and spending time with people you care about can improve depression symptoms.
  • Counseling: Counseling or psychotherapy is talking with a mental health professional. Your counselor helps you address your problems and develop coping skills. Sometimes brief therapy is all you need. Other people continue therapy longer.
  • Alternative medicine: People with mild depression or ongoing symptoms can improve their well-being with complementary therapy. Therapy may include massage, acupuncture, hypnosis and biofeedback.
  • Medication: Prescription medicine called antidepressants can help change brain chemistry that causes depression. Antidepressants can take a few weeks to have an effect. Some antidepressants have side effects, which often improve with time. If they dont, talk to your provider. A different medications may work better for you.
  • Brain stimulation therapy: Brain stimulation therapy can help people who have severe depression or depression with psychosis. Types of brain stimulation therapy include electroconvulsive therapy , transcranial magnetic stimulation and vagus nerve stimulation .

Can Major Depression Be Prevented

Once you have had an episode of major depression, you are at high risk of having another. The best way to prevent another episode of depression is to be aware of the triggers or causes of major depression and to continue taking the prescribed medication to avoid relapse. It is also important to know what the symptoms of major depression are and to talk with your doctor early if you have any of these symptoms.

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Major Depressive Disorder And Relationships

When it comes to talking about how depression affects relationships, Iâm the expert. And itâs not just because Iâm a psychologist. Iâve lived with major depressive disorder since I was 19. I not only work on this issue with my patients, but I encounter it in my own life every single day.

Thereâs no doubt that strong relationships can help provide a buffer against depression and lessen the severity of depressive episodes. One study, for example, followed American adults aged 25-75 for 10 years and found that people who reported poor relationships with their spouse or other family members were at higher risk of depression.

But it can be hard to maintain relationships when youâre hurting so much yourself. Hereâs what I tell my patients and what I want everyone who experiences depression, and those who care about them, to know.

Depression can be hard to understand because itâs an âinvisibleâ illness. This is especially true if you struggle with it yourself. Most of us âgetâ that a broken leg is an injury, for example, and that we need a cast and crutches so we can move around. But if you have symptoms of depression such as moodiness, difficulty concentrating, trouble sleeping, and just generally feeling sad and uninterested in anything, it can be hard to resist the temptation to just tell yourself to snap out of it.

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What Can I Do If I Have Depression

Management Of Depression

If you have symptoms of depression, see your healthcare provider. They can give you an accurate diagnosis, refer you to a specialist or suggest treatment options.

If you or someone you know is thinking of hurting themselves or taking their own life:

  • Go to the emergency department of your hospital.
  • Contact a healthcare provider.

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Key Points About Depression

  • Depression is a serious mood disorder that affects your whole body including your mood and thoughts.

  • Its caused by a chemical imbalance in the brain. Some types of depression seem to run in families.

  • Depression causes ongoing, extreme feelings of sadness, helplessness, hopeless, and irritability. These feelings are usually a noticeable change from whats normal for you, and they last for more than two weeks.

  • Depression may be diagnosed after a careful psychiatric exam and medical history done by a mental health professional.

  • Depression is most often treated with medicine or therapy, or a combination of both.

How Is Major Depression Diagnosed

A health professional — such as your primary care doctor or a psychiatrist — will perform a thorough medical evaluation. You might receive a screening for depression at a regular doctorââ¬â¢s visit. The professional will ask about your personal and family psychiatric history and ask you questions that screen for the symptoms of major depression.

There is no blood test, X-ray, or other laboratory test that can be used to diagnose major depression. However, your doctor may run blood tests to help detect any other medical problems that have symptoms similar to those of depression. For example, hypothyroidism can cause some of the same symptoms as depression, as can alcohol or drug use and abuse, some medications, and stroke.

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How Is Major Depressive Disorder Treated

MDD is often treated with medication and psychotherapy. Some lifestyle adjustments can also help ease certain symptoms.

People who have severe MDD or have thoughts of harming themselves may need to stay in a hospital during treatment. Some might also need to take part in an outpatient treatment program until symptoms improve.

Treatment Options For Management For Depression

Clinical depression – major, post-partum, atypical, melancholic, persistent

Treatment options for management of depression can be broadly be divided into antidepressants, electroconvulsive therapy and psychosocial interventions. Other less commonly used treatment or treatments used in patients with treatment resistant depression include repetitive transcranial magnetic stimulation , light therapy, transcranial direct stimulation, vagal nerve stimulation, deep brain stimulation and sleep deprivation treatment. In many cases benzodiazepines are used as adjunctive treatment, especially during the initial phase of treatment. Additionally in some cases, lithium and thyroid supplements may be used as an augmenting agent when patient is not responding to antidepressants.

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Symptoms In Different Age Groups

Symptoms in teens

Symptoms parents should be aware of in their teens include the following:

  • onset or increased use of substances
  • poorer academic performance
  • increased social withdrawal/isolation

Symptoms in older adults

Depression symptoms in older adults are similar to other age groups. Its often the cause of physical pain in older adults thats not explained by other medical conditions.

Depression is in people with Alzheimers and related dementias. Its sometimes called geriatric depression.

Older adults with one chronic health condition are

Continuation And Maintenance Management Of Depression: Maintenance Electroconvulsive Therapy

Electroconvulsive therapy is a highly effective treatment for depression, including treatment resistant MDD . For example, one study found that, overall, 73% of people with MDD who received ECT achieved remission of those who had at least one adequate prior antidepressant trial, 63% responded, compared with 91% of people without an adequate prior treatment . Most studies have found that approximately 60% of treatment-resistant patients achieve response . However, a relatively high proportion of people who achieve adequate initial response eventually relapse . Sackeim and colleagues found that 84% of ECT-treated patients who continue on placebo relapse within 6 months. This rate was reduced to 60% if people continued on the tricyclic antidepressant nortriptyline. However, only 39% of people treated with a combination of lithium and nortriptyline relapsed, indicating that this combination may be the most effective means of preventing relapse with pharmacotherapy.

Only one relatively small, randomized trial compared combined nortriptyline and ECT against nortriptyline alone in elderly depressed over a 2-year period and found the combination superior . However, there have been no other published studies on the relative benefits of combined medications and C-ECT or M-ECT. In addition, whether C-ECT or M-ECT given on a more frequent schedule would work better is unknown.

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What Is The Outlook For Someone With Major Depressive Disorder

While someone with MDD can feel hopeless at times, its important to remember that the disorder can be treated successfully. There is hope.

Sticking with a treatment plan is a critical part of improving your outlook. Try not to miss therapy sessions or follow-up appointments with your mental health professional.

Similarly, its important not to stop taking your medications unless a mental health or healthcare professional advises you to.

On days when you feel particularly depressed despite treatment, it can be helpful to call a local crisis or mental health service. Resources are available.

A friendly, supportive voice could be just what you need to get you through a difficult time.

Tips For Living Well With Major Depressive Disorder

Malaysian Family Physicians

Living with major depression can feel lonely. People may be fearful or ashamed of being labeled with a serious mental illness, causing them to suffer in silence, rather than get help. In fact, most people with major depression never seek the right treatment. But those struggling with this illness are not alone. Its one of the most common and most treatable mental health disorders. With early, continuous treatment, people can gain control of their symptoms, feel better, and get back to enjoying their lives.

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How Is Depression Treated

Treatment for depression may include one or a combination of the following:

  • Medicine. Antidepressants work by affecting the brain chemicals. Know that it takes 4 to 6 weeks for these medicines to have a full effect. Keep taking the medicine, even if it doesnt seem to be working at first. Never stop taking your medicine without first talking to your healthcare provider. Some people have to switch medicines or add medicines to get results. Work closely with your healthcare provider to find treatment that works for you.

  • Therapy. This is most often cognitive behavioral and/or interpersonal therapy. It focuses on changing the distorted views you have of yourself and your situation. It also works to improve relationships, and identify and manage stressors in your life.

  • Electroconvulsive therapy . This treatment may be used to treat severe, life-threatening depression that has not responded to medicines. A mild electrical current is passed through the brain. This triggers a brief seizure. For unknown reasons, the seizures help restore the normal balance of chemicals in the brain and ease symptoms.

With treatment, you should feel better within a few weeks. Without treatment, symptoms can last for weeks, months, or even years. Continued treatment may help to prevent depression from appearing again.

Discontinuation Of Active Treatment

The factors to discontinue treatment are based on the same considerations in deciding on using maintenance phase therapy: frequency and severity of recurrent episodes, dysthymic symptoms between episodes, the presence of other psychiatric disorders, the presence of chronic general medical disorders, or patient preference. If maintenance pharmacotherapy is discontinued, it is recommended to taper the medication over several weeks. Slow tapering may allow the physician to detect emerging symptoms and restore the medical management to full therapeutic doses. Discontinuation syndromes can appear much like relapses but are in fact due to lack of tapering of medications. Patients on short acting agents are more prone to discontinuation syndromes and should be tapered over longer periods of time. Signs and symptoms of relapse should again be reviewed with the patient once discontinuation of treatment has occurred.

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What Are The Symptoms Of Major Depressive Disorder

A doctor or a mental health professional can diagnose MDD based on your symptoms, feelings, and behaviors.

Typically, youll be asked specific questions or given a questionnaire so health professionals can better determine whether you have MDD or another condition.

To be diagnosed with MDD, you need to meet the symptom criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition . This manual helps medical professionals diagnose mental health conditions.

According to its criteria:

  • You must experience a change in your previous functioning.
  • Symptoms must occur for a period of 2 or more weeks.
  • At least one symptom is either depressed mood or loss of interest or pleasure.

You must also experience five or more of the following symptoms in the 2-week period:

  • You feel sad or irritable most of the day, nearly every day.
  • Youre less interested in most activities you once enjoyed.
  • You suddenly lose or gain weight or have a change in appetite.
  • You have trouble falling asleep or want to sleep more than usual.
  • You experience feelings of restlessness.
  • You feel unusually tired and have a lack of energy.
  • You feel worthless or guilty, often about things that wouldnt usually make you feel that way.
  • You have difficulty concentrating, thinking, or making decisions.
  • You think about harming yourself or suicide.

Deterrence And Patient Education

Do You Know these 5 Types of Depression?

Patient education has a profound impact on the overall outcome of major depressive disorder. Since MDD is one of the most common psychiatric disorders causing disability worldwide and people in different parts of the world are hesitant to discuss and seek treatment for depression due to the stigma associated with mental illness, educating patients is very crucial for their better understanding of the mental illness and better compliance with the mental health treatment. Family education also plays an important role in the successful treatment of MDD.

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Evaluate The Safety Of Patient And Others

A careful assessment of the patient’s risk for suicide should be done. During history inquiry for the presence of suicidal ideation and other associated factors like presence of psychotic symptoms, severe anxiety, panic attacks and alcohol or substance abuse which increases the risk of suicide need to be evaluated. It has been found that severity of depressive symptomatology is a strong predictor of suicidal ideation over time in elderly patients. Evaluation also includes history of past suicide attempts including the nature of those attempts. Patients also need to be asked about suicide in their family history. During the mental status examinations besides enquiring about the suicidal ideations, it is also important to enquire about the degree to which the patient intends to act on the suicidal ideation and the extent to which the patient has made plans or begun to prepare for suicide. The availability of means for suicide be inquired about and a judgment may be made concerning the lethality of those means. Patients who are found to possess suicidal or homicidal ideation, intention or plans require close monitoring. Measures such as hospitalization may be considered for those at significant risk.

When To Seek Emergency Help

If you think you may hurt yourself or attempt to take your own life, call 911 or your local emergency number immediately.

You may also want to consider these options:

  • Call a suicide hotline, such as the 988 Suicide & Crisis Lifeline at 988. Use 988 and press 1 to reach the Veterans Crisis Line.
  • Reach out to a close friend or loved one.

If you have a loved one whos thinking about suicide or has made a suicide attempt, make sure someone stays with that person. Call 911 or your local emergency number immediately. Or, if you think you can do so safely, take the person to the nearest hospital emergency room.

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Psychological Treatments For Depression

Psychological treatments have been found to be an effective way to treat depression. They can help you change your thinking patterns and improve your coping skills so you’re better equipped to deal with life’s stresses and conflicts.

As well as supporting your recovery, psychological therapies can help you stay well by identifying and changing unhelpful thoughts and behaviour.

There are several different types of psychological treatments including:

  • cognitive behaviour therapy
  • behaviour therapy
  • mindfulness-based cognitive therapy .

CBT is one of the most commonly used psychological therapies. It helps people with depression to monitor and change negative patterns of thinking and improve their coping skills so they are better equipped to deal with lifes stresses and conflicts.

What Are The Symptoms Of Depression

Canmat guidelines for major depressive disorder 2016

While each person may experience symptoms differently, these are the most common symptoms of depression:

  • Lasting sad, anxious, or empty mood

  • Loss of interest in almost all activities

  • Appetite and weight changes

  • Changes in sleep patterns, such as inability to sleep or sleeping too much

  • Slowing of physical activity, speech, and thinking OR agitation, increased restlessness, and irritability

  • Ongoing feelings of worthlessness and/or feelings of undue guilt

  • Trouble concentrating or making decisions

  • Repeating thoughts of death or suicide, wishing to die, or attempting suicide

If you have 5 or more of these symptoms for at least 2 weeks, you may be diagnosed with depression. These feelings are a noticeable change from whats normal for you.

The symptoms of depression may look like other mental health conditions. Always see a healthcare provider for a diagnosis.

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Treatment In Continuation Phase

The goal of continuation phase is to maintain the gains achieved in the acute phase of treatment and prevent relapse of symptoms. The treatment algorithm to be followed is shown in figure-4. Patients who have been treated with antidepressants in the acute phase need to be maintained on same dose of these agents for 16-24 weeks to prevent relapse . There are evidences to support the use of specific psychotherapy in continuation phase to prevent relapse. The use of other somatic modalities may be useful in patients where pharmacology and/or psychotherapy have failed to maintain stability in continuation phase. The frequency of visit during the continuation phase may be determined by patient’s clinical condition as well as the specific treatment being provided. If maintenance phase treatment is not indicated for patients who remain stable following the continuation phase, patients may be considered for discontinuation of treatment. If treatment is discontinued, careful monitoring be done for relapse, and treatment to be promptly reinstituted if relapse occurs.

Algorithm for arriving at the diagnosis of Treatment Resistant Depression

Algorithm for management of Treatment Resistant Depression

Repetitive Transcranial Magnetic Stimulation

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