Depression management

Some interesting points in this BMJ article about depression management:

For mild depression (symptoms fairly manageable), appropriate routes for initial treatment include active monitoring (seeing them at intervals and discussing problems), exercise, and guided self-help. If this isn’t helping, other options include:

  • Group CBT
  • Counselling
  • Problem-solving therapy
  • Behavioural activation (which, as far as I can see from the description, seems in effect to be the BT part of CBT)

Antidepressants are only recommended where the depression is at least of moderate severity (i.e. impacting significantly on life). SSRIs are first-line; mirtazapine, venlafaxine or duloxetine are second-line.

The article also referenced this very large meta-analysis from the Lancet comparing the efficacy/tolerability of different antidepressants. I was concerned to see that my usual standby, citalopram, actually ranked among the least effective. On closer inspection this turned out to be possibly exaggerated due to that particular graph being based on the relative effectiveness in different RCTs; however, I checked out the graph of head-to-head comparisons and it seems that escitalopram does have a statistically significant advantage over citalopram in terms of effectiveness. It looks as though I might need to change my first-line treatment.

Finally, the article advised that ADs should be changed if no effect in the first three weeks, although if there’s a small effect then it might be worth continuing as some people are slow responders. And the reduction in chances of recurrence with six months of ADs after symptoms settle is greater than I thought.

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About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in Credits 2019, Psychiatry. Bookmark the permalink.

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