Stress management and healthy lifestyle changes should be considered first by clinicians as part of a broader approach to managing depression in patients, says the latest Australasian treatment guidelines.

Clinicians should take a broader approach to managing depression in their patients, with treatments “tailored to depressive subtypes and administered with clear steps in mind,” according to new summary guidelines on major depression published this week.

A large group of authors representing the Royal Australian and New Zealand College of Psychiatrists (RANZCP), led by Sydney-based Professor Gin Malhi, have written guideline summaries on major depression and on bipolar disorder, published online by the Medical Journal of Australia.

Both are abridged versions of the RANZCP’s 2015 clinical guidelines, directed “broadly at primary care physicians”.

The depression guidelines emphasise a “biopsychosocial lifestyle approach” and provide the following specific recommendations:

  • Alongside or before prescribing any form of treatment, consideration should be given to the implementation of strategies to manage stress, ensure appropriate sleep hygiene and enable uptake of healthy lifestyle changes.
  • For mild to moderate depression, psychological management alone is an appropriate first line treatment, especially early in the course of illness.
  • For moderate to severe depression, pharmacological management is usually necessary and is recommended first line, ideally in conjunction with psychosocial interventions.

The guidelines “highlight the importance of tailoring care to the individual and creating a collaborative therapeutic relationship, while outlining key considerations for long term treatment strategies”, the authors wrote.

The guideline summary for bipolar disorder provides the following specific recommendations:

  • For mania, all physicians should be able to detect early signs so that treatment can be initiated promptly. At the outset, taper and cease medications with mood-elevating properties and institute measures to reduce stimulation, and transfer the patient to specialist care;
  • For bipolar depression, treatment is complicated and may require trialling treatment combinations. Monotherapy with mood-stabilising agents or second generation antipsychotics has demonstrated efficacy but using combinations of these agents along with antidepressants is sometimes necessary to achieve remission. Commencing adjunctive structured psychosocial treatments in this phase is benign and likely effective;
  • For long term management, physicians should adjust treatment to prevent the recurrence of manic and/or depressive symptoms and optimise functional recovery. Closely monitor the efficacy of pharmacological and psychological treatments, adverse effects and compliance.

For bipolar disorder, lithium as first line therapy “remains the most effective medication for the prevention of relapse and potential suicide, but requires nuanced management from both general practitioners and specialists,” Malhi and colleagues wrote. “The guidelines provide clarity and simplicity for the long term management of bipolar disorder, incorporating the use of new medication and therapies alongside established treatments.”

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