2. Acute Depression

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2. Acute Depression

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Goals of Treatment
- Achieve remission of the symptoms of major depression and return the patient to usual levels of psychosocial functioning.
- Avoid precipitating a manic or hypomanic episode.
Choose an initial treatment modality.
- For patients not yet in treatment for bipolar disorder, initiate either lithium or lamotrigine.
  - As an alternative, especially for more severely ill patients, consider initiating treatment with both lithium and an antidepressant simultaneously (although supporting data are limited).
  - Antidepressant monotherapy is not recommended.
  - Consider ECT for
    - - patients with life-threatening inanition, suicidality, or psychosis or
    - - severe depression during pregnancy.
  - Treatment selection should be guided by illness severity, associated features such as rapid cycling or psychosis, and, where possible, patient preference.
  - Interpersonal therapy and cognitive behavior therapy may be useful when added to pharmacotherapy.
  - Although psychodynamic psychotherapy for bipolar depression has not been empirically studied, it is widely used in combination with medication.
- For patients who suffer a breakthrough depressive episode while on maintenance treatment, optimize the medication dosage.Ensure that serum levels are within the therapeutic range; in some instances, achieve a higher serum level (but still within the therapeutic range).
- If the patient fails to respond to optimized maintenance treatment, consider adding lamotrigine, bupropion, or paroxetine.
  - Alternative next steps include adding another newer antidepressant (e.g., another selective serotonin reuptake inhibitor [SSRI] or venlafaxine) or a monoamine oxidase inhibitor (MAOI).
  - Tricyclic antidepressants may carry a greater risk of precipitating a switch and are not recommended.
  - MAOIs may be difficult to use because of the risk of severe drug and dietary interactions.
  - Psychotic features during depression usually require adjunctive treatment with an antipsychotic medication. Some evidence suggests efficacy for antipsychotic medication (e.g., olanzapine, quetiapine) in treating non-psychotic bipolar depression.
  - Consider ECT for
    - - severe or treatment-resistant depression,
    - - psychotic features, or
    - - catatonic features.
  - Clinicians may elect to use antidepressants earlier for bipolar II depression than for bipolar I depression because patients with bipolar II disorder probably have lower rates of antidepressant-induced switching into hypomania or mania.

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Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.

All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.

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2. Acute Depression

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