Australian and New Zealand clinical practice
guidelines for the treatment of depression
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Depression
Background:The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Ministry of Health.
Method:The CPG team reviewed the treatment outcome literature, consulted with practi-tioners and patients and conducted meta-analys of outcome rearch.
Treatment recommendations:Establish an effective therapeutic relationship; provide the patient with information about the condition, the rationale for treatment, the likelihood of a positive respon and the expected timeframe; consider the patient’s strengths, life stress and supports. Treatment choice depends on the clinician’s skills and the patient’s circum-stances and preferences, and should be guided but not determined by the guidelines. In moderately vere depression, all recognized antide
pressants, cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT) are equally effective; clinicians should consider treatment burdens as well as benefits, including side-effects and toxicity. In vere depres-sion, antidepressant treatment should precede psychological therapy. For depression with psychosis, electroconvulsive therapy (ECT) or a tricyclic combined with an antipsychotic are equally helpful. Treatments for other subtypes are discusd. Caution is necessary in people on other medication or with medical conditions. If respon to an adequate trial of a first-line treatment is poor, another evidence-bad treatment should be ud. Second opinions are uful. Depression has a high rate of recurrence and efforts to reduce this are crucial.
Key words:
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Australian and New Zealand Journal of Psychiatry 2004; 38:389–407
depression, evidence-bad review, treatment guideline.
The guidelines focus on moderate to vere depres-sion in adults treated by mental health professionals. Specialist clinicians should consider, but not be limited to, the treatments recommended. The extensive literature includes systematic reviews of randomid controlled trials (RCTs). Where knowledge is spar, lower orders of evidence have been ud. Other guidelines are
avail-able for the treatment of depression in primary care ttings [1,2] and for children [3].
Treatment should be a partnership between patient, general practitioner (GP) and mental health professional. Engaging with the person is crucial for effective treat-ment. Even when depression is vere and complicated, specialist rvices are involved only during the acute pha, with the GP co-ordinating the longer-term treat-ment plan.
Definitions
While transient lowering of mood is common, persist-ence is qualitatively different. Clinical depression is common, rious and treatable. Untreated, it can result in disability and even death. It tends to be episodic and of
Peter Ellis, Chair (Correspondence)
CPG Team for Treatment of Depression, Wellington School of Medicine and Health Sciences, University of Otago, Wellington, New Zealand. Email: ellis@
Received 13 February 2004; accepted 30 March 2004.
390CPG S FOR TREATMENT OF DEPRESSION
varying verity. Many depresd people have concur-rent physical and other mental health disorders.
Prevalence and verity
Depression is common. In the Australian Mental Health Survey, 4% of adults had a depressive disorder in the past month [4]. Compared with other mental ill-ness, depresd people had higher levels of disability, including vere disability, and ud health rvices more (70% had consulted a health practitioner in the previous month) [5]. Some 43% of tho with depression suffer vere disability (< 30% on the Medical Out-comes Study short form 12) [personal communication Gavin Andrews, Wellington, 2001]. A similar pattern is likely in New Zealand.
Moderate to vere depression is as disabling as congestive heart failure [6,7], and its relapsing nature accounts for one of the highest levels of dia burden of any condition [8].
Some 7% of people who consult a GP, and 40% of tho concerned about their mental health, have clinical depression, often in conjunction with an anxiety or sub-stance abu disorder. Most experience disrupted lives [5]. Depression is common in condary specialist rvices. A third of tho prenting to psychiatric com-munity clinics with depression are verely depresd and need
extended treatment; the remainder need specialist advice to assist their primary healthcare professionals [4].
Depression (and substance abu) is the most likely condition to be comorbid with other physical and psychi-atric disorders, but is often unrecognized by primary healthcare workers [9] and condary physicians [10].
Cour and prognosis
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Depression does occur in children but more often in teenagers. It affects boys and girls equally until age 15, after which it is more common in girls [11]. From ages 11–18 the rate increas from 0.5% to 3.4% for a major depressive episode and from 0.9% to 3.2% for dys-thymic disorder [11,12]. Most major depression begins in the late 20s [13].
Symptoms develop over days to weeks, though there may be anxiety, panic, fearfulness and lowered mood over preceding months. Sudden ont is usually associ-ated with major stress. Untreated moderate episodes last up to 9 months. A third of tho with moderate depres-sion recover with placebo treatments, while half respond to 6–8 weeks of active treatment [14]. An episode may be the harbinger of bipolar disorder or an exacerbation of dysthymic disorder.
The likelihood of recovery in the next month decreas after 6 months, from 15% for months 7–9 to 1–2% up to 5 years [15,16], at which time 12% have not recov-ered [16].
Remission is partial for 20–30% of people with depression, who experience continuing symptoms and social and occupational impairment [15]. Recurrence
Emphasis on good prognosis for major depression in primary care is appropriate. But as depression recurs in 40% of people within a year [17], monitoring and intervention are necessary to prevent relap. A 12-years follow-up of people treated for an index episode, found depressive symptoms prent for 60% of this period and a full depressive episode for 15% [18]. People with three or more episodes have an 80% chance of recurrence over the next 3 years [19].
Long-term studies show even higher rates of recur-rence. A 25-years follow-up of Australians hospitalized with depression found only 1 in 8 remained depression-free, with an average of three episodes. However, a quarter improved in the last decade of follow-up, includ-ing 80% of tho chronically depresd over the first 15 years [20]. Tho with psychotic depression have wor outcomes [17].
Complications
If untreated, depression increas risk of suicide and other violent acts. Some 6% of people diagnod at some time during their lives with major depression will suicide [21], as will 10–15% of tho ever admitted to hospital – a rate 30 times that of the general population [17,22,23]. Of tho with a current major depression 25–50% will attempt suicide [24]. Treatment halves the risk of suicide, especially for men under 30 [25–28]. However, unemployment, isolation, impulsivity and misu of alcohol and drugs increa risk [29,30]. Depression, especially when recurrent or chronic, distress family and friends [31]. It may affect a per-son’s capacity as a parent, and is often associated with occupational dysfunction [32].
Aetiology and risk factors
Many factors protect against, predispo to, or precip-itate depression: genes, childhood experience, previous trauma, social and cultural supports, physical factors (including drugs) and stress [33–38]. Depression occurs more commonly in the young [39,40] and in women, at
RANZCP CPG TEAM FOR TREATMENT OF DEPRESSION391
least in Western society [5,39,41,42], and the latter is not
attributable to postnatal depression alone.留根
Depression affects 5–10% of tho with medical
illness attending primary care and 6–14% of medical and
surgical inpatients [43]. Rates of 50% are associated
with some conditions, for example HIV-AIDS [18,44],
in which prevalence correlates with verity [18], pro-
gression [45], older age [46] and less social support [47].
It is commonly associated with Parkinson’s dia [48],
migraine and chronic pain [49]. Varying rates for specific
conditions reflect differences in socio-demographics,
verity and chronicity. Incread rates may be a direct
effect of physical illness (e.g. hypothyroidism, Cush-
ing’s dia and certain cerebral tumours), a side-effect
of treatment (e.g. steroids and some antihypertensives)
or a reaction to illness.
Method
Key features in developing the clinical practice
guidelines are: (i) a review of literature; (ii) meta-
analys of RCTs; (iii) evidence tables; (iv) drafting by
a group with clinical, rearch and consumer exper-
ti; (v) consultation with patients, cultural consultants
and professionals with specific knowledge in sparly
rearched areas; and (vi) redrafting after wider con-
sultation.
Searches of MEDLINE and PsycLIT (1996–July 2002)
using ‘depression’, ‘major depression’, ‘major depres-植物化妆品
sive disorder’, ‘RCT’, ‘meta-analysis’ and ‘review’,
were supplemented by a manual arch. Studies prior to
1996 were identified from the major meta-analysis of
the Agency for Health Care Policy Rearch [14], more
recent meta-analys, and references identified in the
arch. Key texts, review articles and existing guidelines
were examined.
Randomized controlled trials were included in the
meta-analysis if medication was prescribed in adequate
dos for adequate periods, and if information was avail-
able to calculate an intention-to-treat outcome for a
greater than 50% reduction in verity score (e.g.
个性签名图片Hamilton Rating Scale for Depression, HAM-D). The
minimum HAM-D score [50] was 12 for mild depres-
sion, ≥17 for moderate and ≥ 24 for vere. ‘Numbers needed to treat’ (NNT) and ‘absolute risk reduction’
(ARR) were calculated and summarized using meta-
analys. Confidence intervals for NNTs were calcu-
lated iteratively using STATSDIRECT [51].
The working party’s cultural advisor consulted at
every stage with Maori and the Victorian Transcultural
Psychiatry Unit in Melbourne. The Section of Psycho-
therapy, RANZCP identified publications on dynamic
psychotherapy.
The guidelines are for clinicians in specialist mental health rvices. They mainly focus on people who do not recover from a first episode or have a partial remission, and look to the long-term manage-ment of the 45% at risk of recurrence. A third of tho with depression have a single episode only, and can be adequately treated in primary care ttings, with occa-sional specialist support. However, specialist practice must acknowledge the need for longer-term follow-up and relap prevention.
Asssment
Asssment includes the type, verity and duration of the depression and any coexisting psychiatric or physical disorders. It establishes both contributing stress and the individual’s supports, resources and coping style. Crucially, it considers the risk of suicide or risk to others, either
through an act of violence or through neglect (e.g. in postpartum depression).
Heightened clinical suspicion is esntial to effective diagnosis. ‘Atypical’ prentations are common: teen-agers are not always moro, nor are the elderly always sad. Sadness is neither a necessary nor a sufficient criterion. Symptoms are often vague, and physical complaints may be prominent. Women, especially post-partum, and people under 40 are the most susceptible. In atypical depression the neurovegetative symptoms are the rever of tho usually encountered.
Dysthymia must be distinguished from residual symp-toms of major depression, with diagnosis following at least 6 months after full remission of a major depressive episode. If dysthymia precedes major depression (so-called ‘double depression’), poor outcome is more likely.
Treatment decisions will reflect the key psychological, social and cultural issues contributing to the illness, as well as its subtype, verity and duration.
Severity and depression subtypes
Both verity and subtype are important in lecting treatment (Table 1) [13]. Each category needs differen-tial diagnosis and specific treatment. For most, the risk of recurrence is higher than for uncomplicated depres-sion and continuing treatment is indicated.
Formal asssment of verity (e.g. using the HAM-D [50], the Center for Epidemiological Studies Depression Scale [CES-D] [52], or similar) allows lection of evidence-bad treatments and provides a baline to monitor effectiveness.
392CPG S FOR TREATMENT OF DEPRESSION
Suicide risk
Risk asssment, to lf and others, is a key task at first examination and throughout treatment. Risk to others may ari through paranoid ideation as part of psychotic depression. Risk through neglect is of concern during postpartum depression, for the infant or older siblings. Risk may increa during recovery from a retarded depression (e.g. during early respon to ECT), when inten suicidal ideation persists after recovery of motor activity, allowing the person to act on their ruminations. Evidence that suicide attempts are more common in the early morning (when ward staffing levels are lowest) is not consistent and differs between age groups [53–55]. Management strategies vary with the degree of risk to lf or others. As change can be rapid, review of risk and appropriate support is necessary.
Suicide risk asssment is covered in the RANZCP clinical practice guideline on deliberate lf-harm
(in press) <www.ranzcp>.Investigations and concurrent disorders华为股份
Since concurrent physical or other psychiatric illness are common, investigations are considered at initial asssment, particularly if prentation is atypical or precipitating factors abnt, and are reconsidered if respon is poor.
Current treatment evidence
Beneficial interventions
Good outcomes require sound alliance between pro-fessional and patient, adequate duration of treatment, and co-ordination of treatment (Fig. 1).
An evidence-bad treatment is lected in discussion with the patient, and an effective do (or number of therapy ssions) is monitored by measuring verity of symptoms. Antidepressants are most effective for the most vere depression [56]. If initial respon is poor,
Table 1.Severity and subtypes of depression
Severity of major depression (DSM-IV)
An episode of major depression may be classified as mild, moderate or vere:
Mild episodes: Few symptoms beyond the minimum required to make the diagnosis. Mild disability or the capacity to function normally but with substantial and unusual effort.
Moderate episodes: More than minimum criteria met. Greater functional impairment.
Severe episodes: Most criteria prent. Marked interference with social and/or occupational functioning, producing clear-cut, obrvable disability (e.g. inability to work or to care for children). In the extreme, afflicted people may be totally unable to function socially or occupationally, or even to feed or clothe themlves or to maintain minimal personal hygiene.
The nature of symptoms (e.g. suicidal ideation and behaviour) should also be considered in asssing verity.
Melancholia
Distinguished by characteristic somatic symptoms and psychomotor changes. Esntial feature in DSM-IV is the loss of pleasure in all, or almost all, activities or a lack of respon to usually pleasurable stimuli. ICD-10 does not u the term ‘melancholic’ but calls a similar symptom cluster ‘d
epression with somatic features’. Some argue for the utility of a more restrictively defined melancholia, with greater emphasis on physical, especially motor, symptoms of depression [119]. Considered to be particularly responsive to medication and electroconvulsive therapy.
Major depression with psychotic features
Depression accompanied by hallucinations and/or delusions that are usually, but not always, mood congruent. It is very important to distinguish between the enduring nature of psychotic phenomena in major depression and the transient paranoid ideation/ experiences en in the mood instability of borderline personality disorder.
Atypical depression
Characterized by mood reactivity and two or more of: significant weight gain or incread appetite; hypersomnia; leaden paralysis; and a long-standing pattern of nsitivity to interpersonal rejection (preceding mood disorder), causing significant social or occupational impairment. While a long-established concept, its esntial features are still debated [120].
十一月初八With postpartum ont (postpartum depression)
Ont must be within 4 weeks of the birth.
With asonal pattern (asonal affective disorder)
The ont and remission of major depressive episodes occurs at characteristic times of the year, typically beginning in autumn or winter and remitting in spring.
Reference: [13].
RANZCP CPG TEAM FOR TREATMENT OF DEPRESSION 393
continue treatment or consider switching to a cond or third-line option [57] (Fig. 1). All antidepressants, and to a lesr extent the psychological treatments, have a high relap rate following early discontinuation.
Relevant psychological, social and cultural issues are explicitly considered and befriending programs may assist outcome [58,59].
Behavioural measures are preferable to additional medication for relieving some symptoms. For insomnia,sleep hygiene may help (caffeine restriction/avoidance,alcohol avoidance, adequate exerci, avoiding late meals, etc.). Mild depression
No treatment is more effective than supportive clinical care with psycho-education, supplemented by teaching problem-solving skills [60,61] or by supportive counl-ling [62,63].
Moderate depression
Almost all antidepressants, CBT and IPT are equally effective (and of similar absolute cost in the medium term, although direct costs to patients vary). Of greatest benefit is the therapeutic relationship, which enables agreement on treatment lection and continuation.Regular monitoring for side-effects and encouragement to persist (or change treatment) are helpful.
Table 2 compares antidepressants with placebo, and Table 3 with other antidepressants. All antidepressants and CBT are superior to placebo (standard clinical treat-ment without a specific active pharmacological agent),with NNTs of 4.1–5.5 (20% reduction of average absolute risk over placebo).盐都区教育局
The findings in Table 3 are both more relevant and more robust, due to more and bigger studies. The much larger NNTs reflect the similarity in effectiveness of most antidepressants, though venlafaxine has a small
Figure 1.
Outline of treatment for depression.
