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Psychiatric management consists of interventions and activities that should be initiated and provided during all phases of treatment.

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Establish and maintain a therapeutic alliance.

  • Collaborate with the patient in decision making and attend to the patient's preferences and concerns about treatment.

  • Be aware of transference and countertransference issues.

  • Depressive symptoms may make it harder to develop an alliance.

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Complete the psychiatric assessment.

For general principles and components of a psychiatric evaluation, refer to the American Psychiatric Association's Practice Guideline for the Psychiatric Evaluation of Adults. A complete diagnosis of depression should address the following:

  • History of the present illness and current symptoms

  • Psychiatric history, including symptoms of mania, current and past treatments (including duration and dosages), and responses to treatment

  • General medical history

  • Medications, including prescribed and over-the-counter agents and supplements

  • History of substance use and treatment for substance use disorders

  • Personal history (e.g., psychological development, response to life transitions, major life events)

  • Social, occupational, and family histories

  • Review of the patient's prescribed and over-the-counter medications

  • Review of systems

  • Mental status examination

  • Physical examination (by psychiatrist or by other health care professional)

  • Diagnostic tests as indicated to rule out general medical causes of depressive symptoms

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Evaluate the safety of the patient.

  • Assessment of suicide risk is essential (Table 1). Note, however, that the ability to predict attempted or completed suicide is poor.

  • If the patient demonstrates suicidal or homicidal ideation, intention, or plans, close monitoring is required.

  • Hospitalization should be considered if risk is significant.

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Table Reference Number
Table 1. Factors to Consider in Assessing Suicide Risk
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Establish the appropriate treatment setting.

  • Determine the least restrictive setting that will be most likely to address safety and promote improvement in the patient's condition.

  • Consider the patient's

    • clinical condition, including symptom severity, co-occurring psychiatric or general medical conditions, and level of functioning;

    • available support systems; and

    • ability to adequately care for self, provide reliable feedback to the psychiatrist, and cooperate with treatment.

  • Reevaluate optimal setting on an ongoing basis.

  • Consider hospitalization if the patient

    • poses serious threat of harm to self or others (involuntary hospitalization may be necessary if patient refuses);

    • is severely ill and lacks adequate social supports (alternatively, intensive day treatment may be appropriate);

    • has certain co-occurring psychiatric or general medical conditions; or

    • has not responded adequately to outpatient treatment.

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Evaluate and address functional impairments and quality of life.

  • Identify impairments in domains such as work, school, family, social relationships, leisure activities, and maintenance of health and hygiene.

  • Provide interventions to maximize the patient's level of functioning and quality of life.

  • Help the patient to set goals appropriate to his or her level of functioning and symptom severity.

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Coordinate the patient's care with other clinicians.

All clinicians involved in the patient's care should have sufficient ongoing contact with the patient and with one another to ensure that care is coordinated, relevant information is available to guide treatment decisions, and treatments are synchronized.

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Monitor the patient's psychiatric status.

  • Carefully monitor the patient's response to treatment, including

    • symptomatic status, including functional status and quality of life;

    • degree of danger to self and others;

    • signs of "switch" to mania;

    • other mental disorders, including alcohol and other substance use disorders;

    • general medical conditions;

    • side effects of treatment; and

    • adherence to treatment plan.

  • If symptoms change significantly or if new symptoms emerge, consider diagnostic reevaluation.

  • Often family members or caregivers notice changes in the status of the patient first and are therefore able to provide valuable input.

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Integrate measurements into psychiatric management.

  • Match the treatment plan to the needs of the patient by systematically assessing symptoms of the illness and effects of treatment.

  • Consider facilitating this matching by integrating clinician- and/or patient-administered rating scale measurements into initial and ongoing evaluation. (The full guideline provides more discussion of available scales.)

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Enhance treatment adherence.

  • Assess potential barriers to treatment adherence—for example, lack of motivation or excessive pessimism due to depression; side effects of treatment; problems in the therapeutic relationship; and logistical, economic, or cultural barriers to treatment.

  • Collaborate with the patient (and, if possible, the family) to minimize barriers.

  • Encourage the patient to articulate concerns about treatment or its side effects, and consider the patient's preferences when developing or modifying the treatment plan.

  • Recognize that during the acute phase, depressed patients may be poorly motivated and unduly pessimistic and may suffer deficits of memory. During the maintenance phase, euthymic patients may undervalue the benefits and focus on the burdens of treatment.

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Provide education to the patient and, when appropriate, to the family.

  • Use language that is readibly understandable to the patient.

  • Clarify common misperceptions about the illness (e.g., depression is not a real illness) and about treatment (e.g., antidepressants are addictive).

  • Educate about the need for a full course of treatment, the risk of relapse, early recognition of recurrent symptoms, and the importance of obtaining treatment early.

  • Emphasize

    • when and how often to take medication;

    • the typical 2- to 4-week lag for beneficial effects to be noticed;

    • the need to continue medication even after feeling better;

    • the need to consult with the prescribing doctor before medication discontinuation;

    • what to do if problems arise; and

    • the need to taper antidepressants when discontinuing them.

  • Promote healthy behaviors such as exercise, good sleep hygiene, good nutrition, and decreased use of tobacco, alcohol, and other potentially deleterious substances.

Table Reference Number
Table 1. Factors to Consider in Assessing Suicide Risk

References

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