Depression

Objectives

1. In a patient with a diagnosis of depression:
   • Assess the patient for the risk of suicide
   • Decide on appropriate management (i.e., hospitalization or close follow-up, which will depend, for example, on severity of symptoms, psychotic features, and suicide risk)
2. Identify patients who may be at a higher risk for depression (e.g., certain socio-economic groups, those who suffer from substance abuse, postpartum women, people with chronic pain) and assess appropriately.
3. In patients who have medically unexplained symptoms consider and assess for depression.
4. After a diagnosis of depression is made look for and diagnose other comorbid psychiatric conditions (e.g., anxiety, bipolar disorder, personality disorder).
5. In a patient diagnosed with depression:
   • Manage appropriately (e.g., medications, psychotherapy, supported self-management)
   • Monitor their response to therapy and modify appropriately (e.g., augmentation, dose changes, medication changes)
   • Reassess the patient’s safety
   • Set goals, including a return-to-work plan
   • Refer as necessary (including community resources)
6. In a patient presenting with symptoms consistent with depression consider and rule out serious organic pathology using a targeted history, physical examination, and investigations (especially in elderly or difficult patients).
7. In patients presenting with depression inquire about abuse:
   • Sexual, physical, and emotional abuse (past and current, witnessed or inflicted)
   • Addictions (e.g., substance use/abuse, gambling)
8. In a patient with symptoms of depression differentiate major depression from adjustment disorder, dysthymia, and a grief reaction.
9. Following failure of an appropriate treatment in a patient with depression consider other diagnoses (e.g., bipolar disorder, schizoaffective disorder, organic disease).
10. In very young and elderly patients presenting with changes in behaviour consider the diagnosis of depression (as they may not present with classic features).
11. When treating a patient with antidepressants use them in a selective and careful manner, adapted to the presentation and the needs of the individual patient, by:
    • Selecting the most appropriate antidepressant and dose for the patient based on patient factors and on pharmacological factors (e.g., possible drug interactions)
    • Monitoring medication effectiveness, including adherence and the patient’s possible self-medication using other substances (e.g., herbal and naturopathic remedies, alcohol, cannabis)
    • Considering augmentation strategies when appropriate
    • Monitoring side effects carefully when initiating treatment, especially in young and elderly patients
    • Discontinuing medication gradually, monitoring for relapse, recognizing risk, and following response
12. When developing a return-to-work plan for a patient who is being treated for depression:
    • Assess the impact of residual symptoms on work hardiness, performance, and safety
    • Communicate with the patient and the workplace to ensure the plan is realistic and provides clear guidance