Introduction

Supported in part by National Institute of Mental Health (NIMH) Center Grant MH-30915 to the Department of Psychiatry, University of Pittsburgh Medical Center and Western Psychiatric Institute and Clinic, and by the Sarah M. and Charles E. Seay Center for Basic and Applied Research in Psychiatry to the Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas. The authors appreciate the substantive and editorial critiques from Craig Nelson, M.D., and Glen Gabbard, M.D. The authors also thank David Savage for secretarial assistance, and Kenneth Z. Altshuler, M.D., Stanton Sharp Distinguished Chair and Chairman, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, for administrative support.

The authors of the previous section in this section have reviewed the evidence for the efficacy of and relative indications for specific mood disorder treatments. This empirically based knowledge is derived from groups of patients under study. However, clinicians apply that knowledge to individuals. In so doing, they confront a number of strategic and tactical issues that form the subject of this section. Some of these issues have been touched on in discussions of treatment-resistant mood disorders and the management of mood disorders associated with general medical conditions. In this section we provide strategic and tactical recommendations for the treatment of clinical depression based on available clinical research.

Depressed patients can overwhelm practitioners with both the frequency and the magnitude of their life events and/or psychosocial difficulties, in addition to the magnitude, duration, and severity of their depressive symptoms. A strategic plan with specific objectives for each step in the treatment and with assessments of how well each objective is being met may help to make treatment more efficient and effective.

 

Strategies and Tactics in the Treatment of Depression Introduction Acute-Phase Treatment -General Issues -Strategic Issues -Tactical Issues -Treatment With Medication and Formal Psychotherapy Continuation-Phase Treatment Maintenance-Phase Treatment Patient Preference Conclusions Antidepressant and Antimanic Medications Depression-Focused Psychotherapies Psychodynamic Psychotherapies Combined Medication and Psychotherapy Electroconvulsive Therapy Light Therapy Treatment-Resistant Mood Disorders Treatment of Mood Disorders in the Medically Ill Patient

It is now well accepted that the basic phases of treatment are the acute, continuation, and maintenance phases. Acute treatment aims to achieve symptom remission and restoration of psychosocial functioning (also an objective of the continuation phase). Continuation-phase treatment aims at the prevention of relapse, whereas preventing new episodes (recurrences) is the aim of the maintenance phase. Patients who do not experience recurrences or chronic depression are typically not candidates for maintenance treatment.

Acute-phase treatment begins with practitioners and patients choosing a treatment setting (e.g., outpatient, day hospital, or inpatient). Where treatment is delivered depends on factors such as 1) the imminent risk of suicide, 2) the patient’s capacity to recognize and follow instructions or recommendations (i.e., adherence in the face of psychosis), 3) the availability of psychosocial resources, 4) the level of psychosocial stressors, and 5) the patient’s degree of functional impairment.

Which professionals should provide which treatments depends, in part, on patient preference and, more recently, on the structure of managed care programs. Optimally, patients who need to see psychiatrists are those with diagnostic problems; those with severe psychotic, recurrent, and chronic mood disorders; or those who have not fully responded to one or two (at the most) prior treatment trials by nonpsychiatrists. In addition, psychiatrists are essential for patients who require special treatments for which safe delivery is a primary concern (e.g., electroconvulsive therapy [ECT], light therapy, monoamine oxidase inhibitors [MAOIs]) or for those who require complex medication regimens (see Depression Guideline Panel 1993; Paykel and Priest 1992).

Next, a strategic choice must be made among the four major acute-phase treatment strategies (i.e., medication, psychotherapy, the combination of medication and psychotherapy, or ECT). For some patients, light therapy may also be an option. Once the acute-phase treatment is chosen, it is advisable to anticipate common problems and to apply tactics to overcome those problems. Tactics are devised to ensure an adequate trial (e.g., adequate dosage and duration) to determine whether the strategic acute-phase treatment selected was effective. The most important issue is adherence, which can be affected by 1) the nature and severity of side effects, 2) the conscious or unconscious meanings patients attach to taking medication(s), or 3) the patient’s desire to leave treatment (medication or psychotherapy) once he or she has improved, perhaps because of the shame and stigma that still surround depression and other psychiatric disorders (Lin et al. 1995). Since the aim is symptom remission, not just improvement (response), careful interviewing, perhaps supplemented by a symptom rating scale, is essential.

Strategic issues involve what treatments to use, whereas tactical issues focus on how to conduct or implement those treatments (the strategic decisions) in an optimal fashion. The following sections address both strategic (initial treatment selection, subsequent revisions in the treatment plan, and continuation- and maintenance-phase treatment planning) and tactical issues.

In general, should the patient respond to medication in the acute phase (alone or in combination), the same medication at the same dosage is used in the continuation phase. For acute-phase ECT responders, continuation-phase medication is essential. If medication proves ineffective, continuation ECT may be needed (Sackeim et al. 1990). However, this recommendation is based on open case series. No randomized comparative trials of continuation-phase ECT are yet available, although a multicenter randomized trial comparing the efficacy of continuation-phase ECT with continuation pharmacotherapy (nortriptyline) is currently under way. There also are no randomized controlled trials of psychotherapy alone as a continuation-phase treatment, although findings from the few studies that address this issue are consistent with the notion that patients who respond to acute-phase psychotherapy alone may require continuation-phase psychotherapy, albeit with less frequent sessions than in the acute phase, for the subsequent 6- to 8-month period (Blackburn and Moore 1997; Blackburn et al. 1986; Jarrett et al. 1998).