Tratamento para Depressão Maior

Psicopatologia da depressão maior em animação:

Texto sobre eficácia e eficiência de antidepressivos (Assessing and Enhancing the Effectiveness of Antidepressants, por Steve Balt) [Link]

Link para baixar o guideline NICE para tratamento de depressão
http://www.nice.org.uk/nicemedia/live/12329/45890/45890.pdf
Link para baixar o guideline CANMAT para tratamento de depressão:
http://www.canmat.org/resources/CANMAT%20Depression%20Guidelines%202009.pdf

Há outros guidelines importantes.
Abaixo segue um "clipping" de artigos sobre alguns outros guidelines e benefícios de seguir guidelines para depressão.

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Dtsch Arztebl Int. 2010 Oct;107(40):700-8. Epub 2010 Oct 8.

Unipolar depression: diagnostic and therapeutic recommendations from the current S3/National Clinical Practice Guideline.

Härter M, Klesse C, Bermejo I, Schneider F, Berger M.

Source

Institut und Poliklinik für Medizinische Psychologie, Universi -tätsklinikum Hamburg-Eppendorf, Hamburg, Germany. m.haerter@uke.de

Abstract

BACKGROUND: Depressive disorders are among the most common illnesses and reasons for obtaining health care. Their diagnosis and treatment are still in need of improvement. In Germany, a new S3/National Clinical Practice Guideline has been developed for this purpose.METHODS: The existing guidelines on unipolar depression from Germany and other countries were synoptically compared and supplemented with systematic literature searches. After 14 consensus conferences, a total of 107 evidence-based recommendations were issued.RESULTS: Unipolar depression should be diagnosed in accordance with ICD-10 criteria. Screening questionnaires are useful aids to diagnostic classification. When a treatment is chosen, shared decision-making with the patient is essential. Mild depressive episodes can be treated initially by watchful waiting for 14 days. For moderate depressive episodes, pharmacotherapy and psychotherapy are equally effective treatment options. For severe depression, a combination of pharmacotherapy and psychotherapy is recommended. If 4 to 6 weeks of acute therapy are insufficiently effective, lithium augmentation is recommended, rather than combination antidepressant therapy or a switch to another antidepressant. After remission, maintenance therapy should be continued for 4 to 9 months. In recurrent depression, pharmacotherapy and/or psychotherapy, where appropriate, should be continued for at least two years. Specific recommendations are given for patients who have somatic or mental comorbidities or are acutely suicidal, and recommendations are also given for coordination of care.CONCLUSION: This guideline is a comprehensive set of evidence- and consensus-based recommendations for the diagnosis and treatment of unipolar depression. An improvement in the care of patients with unipolar depression will require broad implementation of the guideline, both in the inpatient and outpatient setting.

Acta Psychiatr Scand. 2010 Mar;121(3):180-9. Epub 2009 Oct 30.

An algorithm for the pharmacological treatment of depression.

Spijker J, Nolen WA.

Source

De Gelderse Roos, Mental Health Care, Ede, the Netherlands. JSpijker@trimbos.nl

Abstract

OBJECTIVE: Non-response to treatment with antidepressants (AD) is a clinical problem.METHOD: The algorithm for pharmacological treatment of the Dutch multidisciplinary guideline for depression is compared with four other algorithms.RESULTS: The Dutch algorithm consists of five subsequent steps. Treatment is started with one out of many optional ADs (step 1); in case of non-response after 4-10 weeks, best evidence is for switching to another AD (step 2); next step is augmentation with lithium as the best option (step 3); the next step is a monoamine oxidase inhibitor (MAOI) (step 4); and finally electroconvulsive therapy (step 5). There are major differences with other algorithms regarding timing of augmentation step, best agents for augmentation and role of MAOI.CONCLUSION: Algorithms for AD treatment vary according to national and local preferences. Although the evidence for most of the treatment strategies is rather meagre, an AD algorithm appears to be an useful instrument in clinical practice.




  

Psychiatry Clin Neurosci. 2009 Oct;63(5):652-7. Epub 2009 Aug 10.

Algorithm-guided treatment versus treatment as usual for major depression.

Yoshino A, Sawamura T, Kobayashi N, Kurauchi S, Matsumoto A, Nomura S.

Source

Department of Psychiatry, National Defense Medical College, Saitama, Japan. aihide@ndmc.ac.jp

Abstract

AIMS: The remission rates for patients with major depressive disorder (MDD) during algorithm-guided treatment (AGT), which consisted of four treatment strategy steps were prospectively compared with treatment as usual (TAU).METHODS: The remission rates of patients with mild or moderate MDD during AGT (n = 83) were compared with TAU (n = 127).RESULTS: The remission rate in the AGT group (60.2%) was approximately 10% greater than that in the TAU group (49.7%). The median number of days to achieve remission in the AGT group (93 days) was half as long as that in the TAU group (191 days). The hazard ratio of remission was 1.5 (95% confidence interval: = 1.2-1.8). A higher rate of lithium augmentation in the AGT group (20.5%) compared to the TAU (4.7%) may have led to the greater remission rate. Most participants who did not achieve remission either during the initial or second treatment steps dropped out from AGT.CONCLUSIONS: AGT may be superior to TAU for patients with mild or moderate MDD, based on the remission rates achieved. The later treatment steps in the AGT, however, were rarely utilized because participants who did not receive any benefit dropped out early.




 

Br J Psychiatry. 2006 Dec;189:494-501.

Treatment options in moderate and severe depression: decision analysis supporting a clinical guideline.

Simon J, Pilling S, Burbeck R, Goldberg D.

Source

Health Economics Research Centre, Old Road Campus, Headington, Oxford OX3 7LF, UK. judit.simon@dphpc.ox.ac.uk

Abstract

BACKGROUND: Treatment options for depression include antidepressants, psychological therapy and a combination of the two.AIMS: To develop cost-effective clinical guidelines.METHOD: Systematic literature reviews were used to identify clinical, utility and cost data. A decision analysis was then conducted to compare the benefits and costs of antidepressants with combination therapy for moderate and severe depression in secondary care in the UK.RESULTS: Over the 15-month analysis period, combination therapy resulted in higher costs and an expected 0.16 increase per person in the probability of remission and no relapse compared with antidepressants. The cost per additional successfully treated patient was 4056 UK pounds (95% CI1400-18300); the cost per quality-adjusted life year gained was 5777 UK pounds (95% CI1900-33 800) for severe depression and 14 540 UK pounds (95% CI 4800-79 400) for moderate depression.CONCLUSIONS: Combination therapy is likely to be a cost-effective first-line secondary care treatment for severe depression. Its cost-effectiveness for moderate depression is more uncertain from current evidence. Targeted combination therapy could improve resource utilisation.

J Clin Psychiatry. 2011 Apr;72(4):e14.

Challenges and algorithm-guided treatment in major depressive disorder.

Shelton RC, Trivedi MH.

Source

Department of Psychiatry, Vanderbilt School of Medicine, Nashville, Tennessee, USA.

Abstract

Major depressive disorder is complicated and difficult to treat, primarily because of its chronic and recurrent nature and the poor efficacy of most pharmacologic treatment options. Until more effective treatments become available, clinicians must focus on optimizing patient outcomes through patient care. Implementing measurement-based care and using treatment algorithms can reduce symptoms of depression and help patients achieve and maintain remission.
© Copyright 2011 Physicians Postgraduate Press, Inc.

 

J Clin Psychiatry. 2009 Dec;70(12):e46.

Treating major depression: antidepressant algorithms.

Thase ME.

Source

Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia Veterans Affairs Medical Center, and Pittsburgh Medical Center, Philadelphia and Pittsburgh, USA.

Abstract

Clinicians currently have a large number of pharmaceutical options available for the treatment of depression, yet not one of these treatments is associated with especially high remission rates. Further complicating the treatment of depression is the fact that the more failed treatment trials a patient undergoes, the lower the odds that remission will be achieved. Therefore, choosing the drug that will be most effective for a particular patient early in the treatment process is essential. Antidepressant treatment algorithms are helpful in this regard.

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Comentário do Prof. Peter Yellowlees sobre estratégias de potencialização do tratamento antidepressivo:

"Among the many strategies used to assist patients with treatment-resistant depression is augmentation of selective serotonin reuptake inhibitor (SSRI) antidepressant therapy with either lithium or an atypical antipsychotic drug. Now a team of investigators ^[1] from the British Medical Journal Technology Assessment Group in London, United Kingdom, have estimated the clinical- and cost-effectiveness of these 2 strategies. Using Cochrane review methodology, they found 12 relevant randomized controlled trials, and despite some methodological concerns they concluded that augmentation of SSRIs with lithium or an atypical antipsychotic drug is likely to be beneficial in patients with treatment-resistant depression, and that there was no statistically significant difference between the 2 augmentation strategies. Cost-effectiveness analyses suggested that augmentation with lithium is less expensive and is consequently more effective overall than augmentation with an atypical antipsychotic agent. Although much more research is needed into the strategies required to treat patients with treatment-resistant depression, this review provides more evidence for the clinical value of augmentation with either lithium or atypical antipsychotics, and reminds us of the importance of using cheaper, well-tried and tested medications such as lithium."