Monitoring

Initial

  • Non-adherence to medication is common, and appears to be associated with a number of adverse clinical outcomes, including increased severity of depression, and increased risk of relapse and hospitalisation. One half or more of patients receiving antidepressants fail to take them at an adequate dose for an adequate duration.[479][480]​ During the 8- to 12-week initiation and titration phase, the first 2 weeks of drug therapy has the greatest discontinuation risk. 

  • Help patients to continue medicine therapy by offering a timely response to adverse effects and by maintaining close contact. Beyond their utility in the diagnostic work-up, features of the history, examination, and laboratory studies can prove vital in monitoring for, and preventing adverse effects from, treatment.[481] Follow up with patients, in person or by telephone, within the first 2 weeks to address adverse effects, suicidality, and acceptance of medication taking, and to reinforce educational messages. Telephone follow-up by a trained nurse is also effective, as is text messaging.[482][483]

Continuation, maintenance, and discontinuation

  • Depending on the speed, stability, and adequacy of response, treatment of depression may require close follow-up for up to 1 year in order to adjust or augment therapy.

  • During the maintenance phase, monitor patients monthly in person or by telephone. It is important to continue assessing adherence, suicidality, and adverse effects.

  • Use the Patient Health Questionnaire-9 (PHQ-9) to assess changes in symptom severity objectively. A 50% decrease in symptom score constitutes an adequate response, and a 25% to 50% change in symptom score may indicate the need to modify treatment.

  • Collaborative care models and digital interventions (e.g., iCBT) may facilitate monitoring. See Management approach.

  • Duration of treatment following the remission of symptoms depends on the prior course of illness. Data on treatment outcomes beyond the initial weeks of treatment are limited, although one systematic review suggests that the efficacy of antidepressants compared with placebo is stable over at least the first 6 months of treatment.[320] In general there appears to be a reduced risk of relapse when antidepressants are continued for 6 months or over.[321][322][323]​​ Continue successful antidepressant treatment for 6-12 months following remission.​[165][322]

  • Discontinuation of antidepressant treatment has consistently been associated with a greater risk of relapse than does continuing treatment, and is therefore a complex clinical decision.[324][325][326]​ For some people at increased risk of relapse, continuation of treatment beyond this period may be required. Shared decision-making is recommended.

  • The World Federation of Societies of Biological Psychiatry (WFSBP) supports the use of maintenance treatment for recurrent depression in some circumstances; WFSBP recommends maintenance treatment for 5-10 years, or indefinitely, for those people at greater risk of recurrent depression, particularly when two or three attempts to withdraw medication have been followed by another episode within a year.[332]​​

  • For patients established on pharmacological treatment for depression, regularly review their antidepressant use to assess efficacy and the presence of any adverse effects, and to ensure that long-term use remains clinically indicated.[272]

  • If discontinuation of a selective serotonin-reuptake inhibitor (SSRI) or a serotonin-noradrenaline reuptake inhibitor (SNRI) is required, slowly decrease the dose to reduce the risk of unpleasant withdrawal symptoms; this may need to take place over several months or longer, and should be done at a rate that is tolerable to the patient.[324][328] Drugs with shorter half-lives (e.g., paroxetine, venlafaxine) require longer periods of taper.[329] A proportionate method of tapering is recommended by some treatment guidelines; this involves reductions as a proportion of the previous dose (e.g., 25%) rather than reducing the dose by a fixed increment each time.[165]​ If the required dose is not available in tablet form, a liquid preparation may be required (if available). Be aware that people’s experiences of withdrawal symptoms can vary substantially from mild and transient to longer-lasting and more severe. Anticipatory discussion with the patient is important, including when and how to seek support from a healthcare professional in the event of withdrawal symptoms.[329] Closely monitor the patient to ensure that any apparent emerging withdrawal symptoms do not in fact represent a relapse of their depression.[272][330] 

  • There is a growing body of evidence supporting the use of psychological therapy for prevention of relapse and recurrence, both when used alone and in combination with pharmacotherapy.[175][333]​​ Specific modalities with demonstrated efficacy for relapse prevention include preventive CBT, mindfulness-based CBT, and interpersonal therapy (IPT).[334]​ There is evidence that switching in the maintenance phase from pharmacotherapy to psychotherapy can be at least as effective in preventing relapse as staying with pharmacotherapy.[333][339]​​

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