Psychiatric Management

      1. Perform a diagnostic evaluation to determine if the diagnosis of depression is warranted or if other psychiatric or medical conditions exist.

      • History of present illness and current symptoms
      • Psychiatric history (e.g., symptoms of mania, previous history of psychiatric treatment, response to previous psychiatric treatments)
      • General medical history
      • History of substance abuse disorders
      • Personal history (e.g. psychological development, response to major life events and transitions)
      • Social history
      • Occupational history
      • Family history
      • Medication review
      • A review of systems
      • A physical examination
      • A mental status examination
      • Diagnostic studies as indicated (e.g., TSH, CBC, Basic Chemistry Profile)
      2. Evaluate for the safety of the patient and of others. This evaluation is crucial.

      • Presence of suicidal or homicidal ideation or plans
      • Access to a means for suicide and the lethality of the means (e.g. access to handguns)
      • Presence of psychotic symptoms (e.g. command hallucinations or delusions)
      • Severe anxiety
      • Concurrent alcohol or substance use
      • History of previous attempts
      • Family history of suicide
      • Recent exposure to another person who committed suicide


      3. Evaluate functional impairment by assessing:

      • Interpersonal relationships
      • Work
      • Living conditions
      • Health and medical related needs


      4. Determine a treatment setting. This can vary from ambulatory settings with a primary care provider only, ambulatory settings with a primary care provider in conjunction with a psychiatrist, day programs, to involuntary psychiatric hospitalization. Criteria for involuntary hospitalization are usually set by local jurisdictions. Patients should be treated in the setting that is the safest and is the most effective. The setting should be reassessed at follow up visits. The following situations require referral to psychiatrist:

      • Suicide risk
      • Bipolar disorder or manic episode
      • Psychotic symptoms
      • Severe decrease in level of functioning (e.g., unable to care for self)
      • Recurrent depression
      • Chronic depression
      • Depression that is refractory to treatment
      • Cardiac disease that requires tricyclic antidepressants treatment (contraindication)
      • Need for electroconvulsive therapy (ECT)
      • Lack of available support system
      • Any diagnostic or treatment questions


      5. Establish and maintain a therapeutic alliance. Major depression is a chronic disease and it requires that the patient actively engages and adheres to long periods of treatment. Symptoms of major depressive disorder (e.g., poor motivation, cognitive dysfunction, pessimism, etc.), side effects of medications, and misunderstandings between the physician and patient can be major obstacles to adherence.

      • Pay attention to concerns patients and their families.
      • The physician should be aware of any transference or countertransference issues with the patient (e.g., frustration or anger from or toward the patient, etc.).


      6. Continue to monitor the patient’s psychiatric status and safety.  With treatment, some symptoms may improve while others emerge.

      • Significant changes in psychiatric status or emergence of new symptoms requires diagnostic and management reassessment.


      7. Provide patient education and, if appropriate, to the patient’s family. Effective education will allow patients to make informed decisions about their treatment and improve adherence.

      • Emphasize that major depression is a “real” illness and not a moral defect.
      • Effective treatment is available and necessary.
      • Discuss anticipated side effects of treatments.
      • Education of family and friends is important
      • Support groups are available for patients and their families


      8. Enhance treatment adherence.

      • It is critical for the physician to monitor the patient closely especially as they begin to feel better as the patient may start to focus on the side effects of treatment rather than the benefits.
      • The patient should be encouraged to verbalize any concerns or issues.
      • Review with the patient when and how often to take their medication.
      • Explain that beneficial effects may take 2 – 4 weeks to be noticed.
      • Explain the need to continue taking the medication even after the patient feels better.
      • Remind the patient the need to consult with a physician before stopping medication.
      • Explain to the patient how to access you, a colleague, or the health care team in case a question or problem arises.
      • Consider issues of polypharmacy especially in elderly patients.
      • Consider the financial impact of medications on patients.
      • Encourage the family to help in the process of adherence.


    9. Work with the patient to address early signs of relapse.

    • Exacerbations and relapse are common in major depressive disorder, and patients and families should be educated on this point.
    • A review of signs and symptoms of relapse with the patient is critical as the next episode may contain different depressive characteristics.
    • Emphasize the need to seek early treatment and intervention if symptoms arise to prevent a full-blown exacerbatio

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