II. Management: General Approach

  1. See Pediatric Depression
  2. See Antepartum Depression
  3. See Depression in Athletes
  4. See Depression in Older Adults
  5. See Postpartum Major Depression
  6. Mild to Moderate Depression (PHQ-9 <16)
    1. Antidepressants (e.g. SSRI) are optional (per patient preference)
    2. Active monitoring of depression
    3. Consider Cognitive Behavioral Therapy
    4. Individual or group therapy
    5. Group Exercise
  7. Severe Depression (PHQ-9 >=16)
    1. Antidepressants (e.g. SSRI, SNRI) AND
    2. Cognitive Behavioral Therapy

III. Management: Medications

IV. Management: Psychotherapy - Reassurance and listening

  1. Instill hope
  2. Consider Cork Analogy
    1. Think of self as cork under water
    2. No matter how much people or events push you under
    3. Eventually you will pop up

V. Management: Psychotherapy - Reinforce Positive Behaviors

  1. Exercise (may increase energy and self esteem)
    1. Likely effective adjunct, although variable evidence (needs more high quality studies)
    2. Blumenthal (1999) Arch Intern Med 159:2349-56 [PubMed]
    3. Cooney (2014) JAMA 311(23): 2432-33 [PubMed]
    4. Dunn (2005) Am J Prev Med 28:1-8 [PubMed]
  2. Yoga
    1. Effective in the treatment of Major Depression
    2. Cramer (2017) J Affect Disord 213:70-77 [PubMed]
  3. Mindfulness Based Interventions
    1. Effective in the treatment of Major Depression
    2. Goldberg (2018) Clin Psychol Rev 59: 52-60 [PubMed]
  4. Healthy Diet
  5. Attending Counseling
  6. Antidepressant Compliance
    1. Reassure that these are not habit forming
    2. Reassure that these are not forever
    3. Establish a therapeutic alliance
  7. Schedule pleasurable activities (esp. with people)
  8. Repair relationships with family and friends
  9. Consider keeping a journal

VI. Management: Psychotherapy - Discourage Negative Behaviors

  1. Challenge negative thoughts
  2. Sleep disturbance
  3. Stress in relationships and work
  4. Poor diet or nutrition
  5. Alcohol use or Alcohol Abuse
  6. Medications that worsen depression (Beta Blockers)

VII. Management: Psychotherapy - Educate family and patient

  1. Greatest risk of Suicide is in early treatment

VIII. Management: Cognitive Behavioral Therapy

  1. Efficacy
    1. At least as effect as pharmacotherapy
    2. Wampold (2002) J Affect Disord 68:159-65 [PubMed]
  2. Summary of Process
    1. Recognize that some Perceptions of reality are false
    2. False Perceptions lead to negative thoughts
    3. Learn to identify negative thoughts as they occur
    4. Replace distorted thoughts with alternatives
    5. Reframe central beliefs about world and self-image
  3. Techniques
    1. Keep a Thought Journal
      1. Identify specific stressful situations
        1. Example: Meeting a new person
      2. Characterize associated mood and automatic reaction
        1. Example: I am anxious - they will hate me
      3. Identify reasons for negative thoughts
        1. Example: Noone speaks with me at parties
      4. Identify counter-arguments
        1. Example: I have close friends who care about me
      5. Substitute negative thought with alternative
        1. Example: I am likeable - be myself
    2. Set goals and activities (example follows)
      1. Goal: Exercise every day, this improves self-esteem
      2. Start: Next thursday, before work
      3. Obstacles: Early wake-up
      4. Strategies to overcome obstacles
        1. Be in bed by 10 pm, with clothes set out for AM
      5. Progress
        1. Jan 4: Arrived gym 20 minutes late, short jog
        2. Jan 5: Overslept, missed workout, bad day
        3. Jan 6: Swam for 40 minutes, feel great

IX. Management: Adjuncts

  1. Audio tape based Patient Education
    1. Small British study of "Coping with Depression" tape
    2. Found to effective adjunct to Depression Management
    3. Blenkiron (2001) Br J Gen Pract 51:366-70 [PubMed]
  2. Website based cognitive-behavioral management
    1. Mood Gym
      1. http://moodgym.anu.edu.au
    2. Effective in Major Depression
      1. Christensen (2004) BMJ 328:265-9 [PubMed]

X. Resources

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