HOW IS MDD TREATED?
A second-generation antidepressant is an appropriate treatment based on side effect profile, cost, and patient preference.1,12 A follow-up visit should be scheduled within 1 to 2 weeks of initiation of therapy and again after 6 to 8 weeks to assess the effectiveness of therapy and inquire about side effects.11 Patients should be asked about adherence to the prescribed regimen and whether they have intrusive thoughts of harm to themselves or to others.11 They should also be reassessed for whether they need to be referred for specialty care (see below). Patients with MDD should continue treatment for a minimum of 4 to 9 months,1 although those with a history of past episodes of MDD may need to extend treatment beyond a year or even indefinitely. In adults, there may be an associated increase in the risk for nonfatal suicide attempts; this is another reason for close followup and screening for suicidal tendencies in all patients who have begun treatment with antidepressant medicines.1,11
Antidepressant medications currently approved for use in children and adolescents include certain selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and limited other medications.13 Generally, the lowest effective dosages of SSRIs are appropriate. Children and adolescents are at higher risk for suicide than adults; the suicide risk is doubled with antidepressant use in this population. Young patients should be followed frequently and carefully.
Combined counseling and pharmacotherapy should be considered for children or adults with mild to moderate MDD in the primary care setting.11,12,14 Combination treatment may offer advantages over either treatment individually.15 Complementary medications (such as St John's wort)16 and alternative treatments such as yoga, relaxation therapy, and massage may also be helpful for some patients who prefer to avoid traditional treatments.
WHEN IS SPECIALTY CARE ADVISED?
Patients should be referred for either inpatient treatment or counseling if they are at immediate risk for suicide or are overwhelmed with hopelessness.10,11 The characteristics associated with increased suicide risk in children and adolescents include depressed mood, psychomotor agitation, and especially feelings of worthlessness.10 Intensive inpatient treatment should be sought for these patients and for those patients with delusions or hallucinations, self- destructive behaviors, or significant comorbidities requiring frequent assessment. If symptoms remain uncontrolled by therapy, patients may need more intensive interventions.1 JAAPA
Acknowledgment: CSAC would like to thank Rod Purdie, MD, and Phebe Tucker, MD, for commenting on early drafts of this article.
This article was written by Daniel L. O'Donoghue, PhD, PA-C, and Gilbert A. Boissonneault, PhD, PA-C. Contributors included the other members and staff of CSAC 2009-2010: Anthony E. Brenneman, MPAS, PA-C; Alison C. Essary, MHPE, PA-C; Frank Fortier, PA-C; Michelle Lynn Heinan, EdD, PA-C; Marie-Michèle Léger, MPH, PA-C; Robert McNellis, MPH, PA; and Thomas Moreau, PA-C, MS. The manuscript was edited by Sarah Zarbock, PA-C.
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