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Step 5: Inpatient care, crisis teams |
Risk to life, severe self-neglect | Medication, combined treatments, ECT |
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Step 4: Mental health specialists including crisis teams |
Treatment-resistant, recurrent, atypical and psychotic depression, and those at significant risk | Medication, complex psychological interventions, combined treatments |
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Step 3:
Primary care team, primary care mental health worker |
Moderate or severe depression | Medication, psychological interventions, social support |
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Step 2:
Primary care team, primary care mental health worker |
Mild depression | Watchful waiting, guided self-help, computerised CBT, exercise, brief psychological interventions |
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Step 1:
GP, practice nurse |
Recognition | Assessment |
Antidepressants are not recommended in the initial treatment of mild depression i.e. steps 1 and 2, because the risk-benefit ratio is poor.
The commencement of medication is clearly identified as part of the management of moderate depression. Antidepressant medication is recommended to be commenced prior to any of the psychological therapies.
Patients who present with severe depression should be considered for a combination of antidepressant medication and individual CBT as this combination is more cost effective than either treatment on its own.
Watchful waiting, a telephone call or consultation monthly.
A consultation or telephone call every 2 weeks.
A consultation or telephone call every week.
It is important to maintain regular contact with the patient with a moderate or severe depression in order to ensure concordance with their antidepressant medication and to ensure there is no relapse of symptoms.
All patients:
Consultation or telephone call every 2-3 months following remission.
Depression is often a chronic disease and continuation of antidepressants for 4-9 months after achieving remission helps to reduce relapse.
40-50% of depressed patients may experience a new episode of depression within 2 years of a first episode of major depression.
Following recurrence of depression the relapse rate increases to 75%.
Long-term maintenance on antidepressants for patients with a recurrence of depression significantly reduces recurrence.
Many patients with a recurrence of symptoms do not seek help immediately, annual monitoring of patients with a history of depression may therefore be useful to detect early signs of relapse.
Clinicians should maintain a high level of suspicion when this group of patients are seen in the interim for other problems.
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and informative material on the subject of depression. Last updated 17 August 2008 Website designed and created by Penny Louch |
