PEER REVIEWED FEATURE 2 CPD POINTS Adult A step-by-step KEY POINTS • A stepwise approach to evidence-based primary guide to mental health care promotes early detection of patients with depression. • Early detection by GPs encourages more timely treatment access to evidence-based treatments, including easily accessed and destigmatising e-mental health JOSEPHINE ANDERSON BA, BMed(Hons), MMed, MHealthLaw, interventions. FRANZCP, Cert Child Adol Psych • Given the overall similarities in efficacy of VERONICA GALVEZ MB BS, MD , the most important considerations COLLEEN LOO MB BS(Hons), FRANZCP, MD when initiating pharmacotherapy are tolerability and PHILIP B. MITCHELL AM, FASSA, MB BS, MD, FRANZCP, FRCPsych safety, although some patients uniquely respond to some medicines and not others. A stepwise approach to the early detection and • For patients with difficult-to-treat depression, an management of depression, guided by severity of algorithmic management approach with steps that presentation and treatment response, can ensure include increasing the dose, switching timely access to treatment. Evidence-based antidepressants, augmenting with a nonantidepressant treatment and combining antidepressants improves treatments range from e-mental health apps, the chance of patient recovery. psychological therapy and to • Neurostimulatory treatments such as electroconvulsive neurostimulation. therapy and repetitive transcranial magnetic stimulation have an expanding role in the evidence-based treatment of severe depression.

ajor depressive disorder occurs in 5% of adults annually and has effects on quality of life equal to or greater than those of ischaemic heart disease or diabetes.1 MedicineToday 2015; 16(11): 16-24 Around 25% of patients who present to their GPs with Amended November 2015 Mdepressive symptoms have major depressive disorder. Nonetheless, currently around 50% of people with this severity of depression Dr Anderson is Conjoint Associate Professor in the School of Psychiatry at the are unable to access or do not receive appropriate care.2 University of New South Wales; and Clinical Director of the Black Dog Institute, In this article, we describe a stepped care approach to the Sydney. Dr Galvez is Visiting Psychiatrist and Clinical Research Officer in the treatment of major depressive disorder in adults, with recom- School of Psychiatry at the University of New South Wales and SyNC (Sydney Neurostimulation Centre), Black Dog Institute, Sydney. Professor Loo is Professor mendations appropriate to patients who present at each level of in the School of Psychiatry at the University of New South Wales; Clinical severity. We focus on early detection and access to evidence-based Academic at St George Hospital; Director of SyNC; Professorial Fellow at the e-mental health, pharmacological and physical treatments, Black Dog Institute; and Director of ECT at Wesley Hospital, Sydney. Scientia including new therapies. Many of the resources and strategies Professor Mitchell is HeadCopyright of the School _Layout of Psychiatry 1 17/01/12 at the University 1:43 PM of NewPage 4 described here have been developed at the Black Dog Institute South Wales; and Professorial Fellow at the Black Dog Institute, Sydney, NSW. in Sydney.

16 MedicineToday ❙ NOVEMBER 2015, VOLUME 16, NUMBER 11 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2015. 1. MAJOR DEPRESSIVE DISORDER: DSM-5 CRITERIA AND SEVERITY CLASSIFICATION6

Criteria for diagnosis • Pervasive depressed mood or loss of interest/pleasure in usual activities together with four or more of the following symptoms, present nearly every day: –– significant weight loss or gain or decrease in appetite –– insomnia or hypersomnia –– psychomotor agitation or retardation –– fatigue or loss of energy –– feelings of worthlessness or excessive or inappropriate guilt –– diminished ability to think or concentrate or indecisiveness –– recurrent thoughts of death or or suicide attempts

Classification of severity • Mild: few if any symptoms in excess of those needed to make the diagnosis and although distress may be evident, the disorder leads to only ‘minor impairment in social or occupational functioning’ • Severe: the number of symptoms is substantially in excess of that required to make the diagnosis, the ‘intensity of the symptoms is seriously distressing and unmanageable’, and symptoms ‘cause marked interference with occupational and social functioning’ • Moderate: between the extremes

Management In the stepped care approach, patients with major depressive disorder are managed according to the severity of their depression on presention, with care being stepped up if there is not sufficient response to treatment.

Step 1: mild depression Patients with mild depression (or mild major depressive disorder) can be observed, educated and advised regarding daily exercise, A stepped approach to care sleep hygiene and mood monitoring (the latter alone can be Detecting and diagnosing major depression associated with positive changes in mood and functioning).7,8 Given the frequency of mental health problems in general practice, E-mental health interventions encourage patients to monitor GPs may wish to screen all patients for symptomatic depression their mood and note the circumstances associated with mood (and associated ) using well validated tools such as the fluctuations. Evidenced-based examples that are available on Patient Health Questionnaire (PHQ-9) or the Generalised A­ nxiety the Internet and smart phones include: Disorder 7 (GAD 7) scale.3-5 These are self-report scales in the • myCompass (free, with a pre-registration overview; public domain. They also help to distinguish mild, moderate and www.mycompass.org.au) severe depression, with implications for treatment recommen- • This Way Up (registration and a small fee are required; dations (see below). https://thiswayup.org.au). In addition, the Diagnostic and Statistical Manual of Mental These programs are readily accessible and destigmatising Disorders, 5th edition (DSM-5) describes the necessary symp- and also provide treatment modules that have proved effective toms for a diagnosis of major depressive disorder and classifi- for the treatment of mild to moderate depression.9 cation of its severity,Copyright which _Layoutmay be 1 mild, 17/01/12 moderate 1:43 PM or Pagesevere 4 At subsequent visits, GPs can review mood monitoring and 6 © MAXIM MALEVICH/DOLLAR PHOTO CLUB. MODEL USED FOR ILLUSTRATIVE ONLY. PURPOSES (Box 1). the treatment modules tried, providing useful springboards for

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conjunction with a psychiatrist. They will Depression is a risk factor for treatment 2. MAJOR DEPRESSION WITH ATYPICAL FEATURES often require antidepressant medication nonadherence, so it is vital to establish a and combined treatments, including more therapeutic alliance and to educate • Symptoms include: complex psychotherapeutic approaches. patients and families about treatment –– presence of mood reactivity and Local public mental health after-hours or adherence. Develop a plan to monitor the lifting of mood in the context of crisis services may also need to be part of patient’s treatment response, side effects pleasant events the patient’s care team. and general medical condition. –– hypersomnia rather than early Remission is the initial goal. Although morning wakening Step 4: severe depression with patients should be reviewed every two –– increased appetite or weight gain marked functional impairment weeks when initiating antidepressants, the rather than anorexia and weight Patients with depression that is accompa- overall response should be assessed at four loss nied by psychotic symptoms, severely weeks, and strategies optimised if the –– a subjective sense of heavy leaden impairs their functioning, has failed to response is inadequate. Up to 10 weeks feelings in the arms or legs rather than observed psychomotor respond to multiple adequate courses of may be required to achieve maximum agitation or retardation antidepressants or is life-threatening may improvement. • Patients also often exhibit a ­ require treatment in hospital. This treat- long-standing pattern of sensitivity to ment may include electroconvulsive Choosing an initial antidepressant interpersonal rejection that results in therapy­ (ECT). When choosing an antidepressant, con- significant social or occupational sider patient factors as well as character- impairment Relapse prevention istics of the drugs. Important patient • Depression can be mild, moderate or Both structured psychotherapy (such factors include: severe as CBT) and antidepressants are effi­cacious • prior experience with in the prevention of relapse or recurrent antidepressants discussion. Reviewing patients at least episodes of depression. For a first episode • history of adherence to treatment fortnightly encourages adherence and of moderate depression, we recommend • preference, especially with regard to allows monitoring of improvement, gen- continuing antidepressants for six months potential side effects such as sexual erally evident within four weeks. after symptom remission. However, in dysfunction RACGP-accredited continuing profes- patients with a clear pattern of multiple • concurrent medical conditions (such sional development training in e-mental ­episodes of moderate or severe depression as cardiac disorders) health primary care is available through over time, antidepressants should be con- • use of nonpsychiatric drugs federally funded initiatives, such as tinued for several years, and even lifelong • suicidality. e-Mental Health in General Practice in those with a history of frequent and Also important is one's own prescrib- (eMHPrac; available online at www.black ­difficult-to-treat recurrences of illness. ing experience with antidepressants. doginstitute.org.au/eMHPrac). Initiating pharmacotherapy Efficacy and tolerability Step 2: moderate depression Consider pharmacotherapy for patients In the treatment of mild to moderate Although patients with moderate depres- with moderate or severe depression, t­ hose depression, no one class of antidepressant sion may also benefit from evidence-based presenting with mild depression that does is quicker in onset or more effective than e-interventions, face-to-face psychological not respond to nonpharmacological other classes. , , therapies are indicated, such as inter­ ­interventions and ­those with a past history ­ and have some personal psychotherapy (IPT) or cognitive of moderate or severe depression. relative benefits when con­sidering the sever- behaviour therapy (CBT). For patients who Before beginning antidepressants, ity of the depressive e­pisode and dosage do not want, cannot access or do not benefit ­reassess the patient’s mental state (includ- required. has a lower response from such psychological therapies, anti­ ing suicidality), the diagnosis and espe- rate than other antidepressants.10 depressants should also be considered. cially the possibility of untreated comorbid Given the similarities in efficacy of ­disorders. For example, anxiety disorders most antidepressants, the most impor- Step 3: severe depression and substance abuse are commonly tant factors to consider in the first choice Patients with depression resistant to the comorbid with depression and require of antidepressant are often tolerability above treatments or who present initially their own evidence-based interventions if and safety (although some patients with severe or melancholicCopyright depression _Layout 1 are 17/01/12 the 1:43patient’s PM depressionPage 4 is to respond fully uniquely respond to some medicines and best managed with the advice of or in to treatment. not others). Overall, selective

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­evidence-based psychological therapies 3. SIDE EFFECTS OF COMMON ANTIDEPRESSANT GROUPS (e.g. CBT, IPT) often have a key role in these patients. Classically, older MAOIs Selective serotonin Serotonin and noradrenaline reuptake have been reported to be effective in inhibitors (SSRIs) inhibitors (SNRIs) ­patients with ­atypical depression; in con- • The most frequent side effects are • Side effects include , , nausea or gastrointestinal pain, somnolence, insomnia, ejaculatory temporary ­practice, these are preferably activation/restlessness, sexual abnormalities, sweating and dry mouth initially ­prescribed by psychiatrists. dysfunction and headaches Increased bleeding risk is associated Major depressive disorder with melan- • Bleeding risk is increased as SSRIs with platelet dysfunction cholic features. This type of depression alter platelet function, especially in Mirtazapine is almost always severe. Key features are: combination with other substances • Rates of cessation due to side effects • marked anhedonia (loss of pleasure influencing platelet dysfunction of weight gain and sedation are similar in almost all activities and/or a lack • There is a risk of hyponatraemia due to to those with SSRIs of reactivity to usually pleasurable syndrome of inappropriate antidiuretic • Nausea and sexual side effects are 6 hormone secretion (SIADH), especially stimuli) less common than with SSRIs in the elderly • together with three or more of the • QTc prolongation has been associated Vortioxetine following features: with high doses of SSRIs (e.g. greater • Side effects are similar to those of –– despondency, despair, moroseness than 40 mg of ) other SSRIs, with nausea the most or ‘empty mood’ common antidepressants (TCAs) –– these symptoms worse in the • Maximum recommended dose is • Anticholinergic, antimuscarinic and morning 10 mg/d in patients known to be cardiovascular side effects mean that –– early morning wakening cytochrome P450 2D6 poor TCAs are relatively contraindicated in – metabolisers12 – marked psychomotor retardation patients with cardiovascular disease • May have a positive cognitive effect or agitation • TCAs are also contraindicated in although this requires further research –– significant anorexia or weight loss patients with narrow angle glaucoma, to verify13 –– excessive or inappropriate guilt. prostatic hypertrophy, cognitive impairment, seizure or delirium Patients with major depressive disorder • Secondary amine TCAs • Poses an increased risk of with melancholic features are nearly always (e.g. ) have fewer side damage with up to a 10-fold increase managed by GPs with advice from or in effects than tertiary amine TCAs in serum transaminase levels and conjunction with a psychiatrist. Anti­ (e.g. ) some reported cases of liver failure, depressants of choice include the well-­ hepatitis and icterus tolerated SSRIs, SNRIs such as v­ enlafaxine, TCAs, MAOIs and the newer antidepres- • TCAs, SSRIs and venlafaxine are more likely to cause sexual dysfunction than sants such as agomelatine and the serotonin , reboxetine and mirtazapine. Agomelatine and perhaps vortioxetine are inhibitor and modulator vortioxetine. the least likely to cause sexual dysfunction Psychotic depression. Major depressive disorder associated with delusions and/or reuptake inhibitors (SSRIs) are generally antidepressant agomelatine or the tetracyclic hallucinations is always severe and has a better tolerated than older style anti­ antidepressant m­ irtazapine may be pre- considerably better response rate when depressants such as tricyclic antidepres- ferred when disturbances of the sleep–wake treated with the combination of an anti­ sants (TCAs) and monoamine oxidase cycle or insomnia are prominent. There is depressant and an than with inhibitors (MAOIs). evidence that the SNRI duloxetine is helpful either alone.11 This benefit must be weighed in patients with comorbid physical pain.10 against potential unwanted effects, such as Significant symptoms extrapyramidal symptoms and the meta- Significant symptoms such as anxiety and Depressive subtype bolic syndrome. Some patients will also insomnia may also influence the initial Atypical depression. Major depression respond better to ECT (see below.) choice of antidepressant. Escitalopram and with atypical features describes depression other SSRIs or the serotonin and nonadren- with key features that are the opposite of profiles aline (SNRI) venlafaxine those in the usual presentation of depres- The side effect profiles of the different can be useful first choices for patients sion (Box 2). classes of antidepressant are summarised with anxious r­ uminationCopyright as _Layouta prominent 1 17/01/12 SSRIs1:43 PM can Page be helpful 4 in the treatment in Box 3.12,13 In general, SSRIs have greater ­associated ­symptom. The melatonergic of patients with atypical depression, and tolerability than other antidepressants.

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rarely result in death. Although serotonin Treatment Alternatives to Relieve 4. ANTIDEPRESSANTS AND SUICIDALITY syndrome can occur idiosyncratically, it Depression) trial of almost 3000 patients is more likely with higher doses. with depression in the USA took an • Epidemiological studies reveal an A handy guide to switching patients ­algorithmic approach to difficult-to- association between a reduction in between antidepressant classes, especially treat depression and found that 70% the frequency of and an to avoid , is available of patients eventually achieved remis- increase in the number of on the Black Dog Institute’s website sion, but only after trying up to four prescriptions for antidepressants in (http://www.blackdoginstitute.org.au/ ­different antidepressant treatment the past two to three decades.17 healthprofessionals/depression/using approaches.25 This highlights the impor- • It has been shown that the risk of 16 suicide is highest in the month before antidepressants/index.cfm). tance of using the best available evidence starting an antidepressant, rapidly in the ­management of difficult-to-treat declines in the first week of Suicidality depression.26 treatment, and continues to decrease Although effective antidepressants reduce Before adopting a pharmacological to even lower stable rates as the intensity of suicidal thoughts over strategy for a patient with difficult-to-treat treatment continues.18 time, there is no specific acute antisuicidal depression, consider: • A meta-analysis of trial data submitted to the US Food and Drug medication. taken prophylacti- • general clinical issues, such as ­incorrect Administration (FDA) confirmed cally prevents both suicide attempts and or missed comorbid­ psychiatric previous findings that suicidal completed suicide but any acute anti­ ­diagnoses (e.g. , behaviour did not differ between suicidal effects are not known.1 Evidence schizophrenia, anxiety ­disorders) as those taking antidepressants and on the relation between antidepressants well as substance abuse, persisting those taking .19 and ­suicidality is discussed in Box 4.17-22 psychosocial issues and treatment • An increase in suicidality (but not Suicidal or young patients commenc- nonadherence completed suicides) among adolescents led to the FDA’s black ing an antidepressant should be seen at • the adequacy of the antidepressant box warning on antidepressant least weekly and frequently thereafter until dose; consider measuring plasma medication for youths in 2004, but the risk of suicide is no longer considered levels of the antidepressant (to several subsequent studies have clinically important.23 identify fast or slow metabolisers shown an inverse relation between or n­ onadherence despite claimed antidepressant prescribing and successful suicide in this age Overdose danger adherence) and the possibility of drug group.20-22 TCAs are the most dangerous of the interactions with nonpsychiatric ­antidepressants in overdose, followed by SNRIs (and others such as mirtazapine), • a review of physical health, including Drug–drug interactions with SSRIs being least dangerous.24 If assessing for poorly controlled pain Some newer antidepressants (venlafaxine, patients with suicidality require one of or a general medical condition that is mirtazapine, duloxetine, agomelatine and the anti­depressants that are more dan- contributing to the depression (Box 5). reboxetine), although also metabolised gerous in overdose then we recommend Although there is no strong evidence through hepatic CYP450 systems, are that only a week’s supply be prescribed supporting the particular order of imple- associated with lower rates of drug–drug (or dispensed) at a time. menting evidence-based pharmacological interactions than SSRIs.14 strategies in patients with difficult-to-treat Serotonin syndrome has been most Evaluating effectiveness of initial depression, the following sequence is commonly due to the interaction of an treatment ­recommended (see Box 6):26 MAOI and an SSRI but can occur with Observer ratings (e.g. the Hamilton Rating 1. increase antidepressant dose other combinations of med- Scale for Depression), patient report 2. switch to different antidepressant ications (e.g. , L-, (e.g. Beck Depression Inventory and the 3. augment with a nonantidepressant , venlafaxine, , St John’s PHQ-9) as well as patient monitoring of agent wort, unregulated performance enhancing mood may all be helpful in determining 4. combine antidepressants. ‘supplements’ and, in rare cases, lithium). response to initial treatment. Sometimes it may be more appropriate Serotonin syndrome can present with to consider augmentation before switching confusion, agitation, myoclonus, hyper- Difficult-to-treat depression antidepressants. Psychological interven- reflexia, sweating, shivering, tremor, Only a third of patients with depression tions or neurostimulatory treatments such abdominal cramps, Copyrightdiarrhoea, _Layout tachycardia 1 17/01/12 initially 1:43 PM treated Page with4 an SSRI achieve as ECT (see below) should be considered and hypotension or hypertension.15 It may remission.25 The STAR*D (Sequenced at each step in management.26

22 MedicineToday ❙ NOVEMBER 2015, VOLUME 16, NUMBER 11 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2015. only a partial response can be helpful. 5. MEDICAL CONDITIONS THAT 6. PHARMACOLOGICAL TREATMENT CONTRIBUTE TO DEPRESSION Some options include: RECOMMENDATIONS FOR • lithium, which is more effective than DIFFICULT-TO-TREAT DEPRESSION26 • Degenerative neurological disorders placebo in augmentation of TCAs, 29 • Cardiovascular diseases SSRIs and other antidepressants. A 1. Increase antidepressant dose • The maximum tolerable approved • Epilepsy once-daily dose to achieve plasma levels of 0.5 to 1.0 mmol/L is recommended dose should be prescribed for at • Brain tumour • atypical . Despite strong least four to six weeks • Endocrine disorders (especially evidence from placebo-controlled 2. If no or partial response, consider thyroid dysfunction, hyper- and switching to another antidepressant hypoadrenocorticism, hyper- and trials that augmenting antidepressants • Different SSRI hypoparathyroidism, diabetes mellitus) with antipsychotics is more effective • Non-SSRI antidepressant (e.g. • Metabolic conditions such as vitamin than augmenting with placebo, any venlafaxine or other SNRI, B12 and folate deficiency such benefits must be weighed against mirtazapine, TCA, MAOI or *) • Systemic autoimmune diseases such unwanted effects such as weight gain, 3. If no or partial response, consider as systemic lupus erythematosus sedation, prolactin increase and augmenting with a nonantidepressant agent • Viral and other infections extrapyramidal side effects. Moreover, • Lithium • Some cancers (e.g. pancreatic and such use of antipsychotics has not been • lung cancer) approved by the TGA in Australia, and 4. If nil or partial response, consider would therefore be considered ‘off-label’ combining antidepressants Maximising the dose of the initial prescribing in this country. • SSRI plus mirtazapine antidepressant Among the atypical antipsychotics, • Mirtazapine plus venlafaxine (or other Increasing the antidepressant dose to the evidence supporting effectiveness is more SNRI) recommended maximum can be helpful ambiguous for . In the case of • SSRI plus TCA for TCAs that have a broad therapeutic range , initial improvement was not • SSRI plus bupropion* (e.g. amitriptyline, clomipramine), tetracy- maintained through continuation phase Abbreviations: 1 MAOI = monoamine oxidase inhibitor; clic antidepressants (e.g. mirtazapine), ven- treatment. For , the recom- SNRI = serotonin and noradrenaline reuptake inhibitor; lafaxine and the MAOI .10,27 mended starting dose is 2 to 5 mg per day, SSRI = selective serotonin reuptake inhibitor; TCA = . Increased doses of SSRIs, however, are with dose adjustments of 5 mg daily at * Bupropion is not approved for the indication of generally­ not more efficacious as there is intervals of no less than one week, with a depression in Australia. usu ­ally 80% receptor occupancy with the maximum dose of 15 mg daily. minimum recommended dose, although extended release should be started at a dose serotonin syndrome (see above) when some studies do suggest a benefit of higher of 50 mg at night, which can be increased ­combining two antidepressants. SSRI doses.28 If a maximum tolerable on day 3 to 150 mg at night. Doses higher approved dose has been administered for than 300 mg daily have not been studied Physical treatments for difficult- four weeks and there is still no response then as an augmentation strategy. to-treat depression switching medications is reasonable. If there In Australia, current approved neuro­ is a partial response then the same dose Combining antidepressants stimulation treatments for patients with could be ­continued for a further four weeks. It has been argued that the combined effects depression are ECT and repetitive tran- of two antidepressants with different mech- scranial magnetic stimulation (rTMS). Switching to a different anisms of action can improve the response Transcranial direct current stimulation is antidepressant in patients with difficult-to-treat depres- in development, with research suggesting The current evidence indicates that after sion. For example, a recent meta-analysis it may emerge as a promising treatment failure to respond to an initial SSRI, found that both TCAs and mirtazapine in for depression in the near future. acceptable next options include a different combination with SSRIs were more effec- SSRI or an antidepressant of a different tive than an SSRI alone in achieving remis- Electroconvulsive therapy class (such as an SNRI). sion, with no difference in rates of drop out ECT is the most effective proven or side effects in those studies that reported ­biological treatment that is currently Augmenting with a non- on these data.30 Nevertheless, not all available for depression. It is prescribed antidepressant research has supported this strategy, nor for severe or treatment-­resistant unipolar Adding use of a nonantidepressantCopyright _Layout to1 an17/01/12 are all1:43 combinations PM Page 4 safe.10 Prescribers must and ­bipolar depression, especially in antidepressant to which there has been be aware, for example, of the danger of patients with psychotic s­ymptoms,

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refusal to eat or high suicide risk.31 In Australia, it is accessible to those with Newer forms of ECT, such as the use of private health insurance in some private Competing interests: Professor Loo has received ultrabrief pulses (‘ultrabrief ECT’) and inpatient and day-patient settings and on research funding from the NHMRC and the Stanley Medical Research Foundation and equipment from bifrontal ECT, have been shown to have a fee-for-service basis in some outpatient Soterix Medical, Neuronetics and Mecta to lesser cognitive side effects than standard treatment centres. support investigator-led research. She has also ECT while still achieving high efficacy.32 Repetitive TMS is suitable for depressed received honoraria from and Astra Zeneca as a conference speaker on topics ECT is a safe procedure, with high levels patients who have not responded to anti- unrelated to these companies’ products. of patient acceptability and satisfaction.33-36 depressant medication, cannot tolerate side Dr Anderson, Dr Galvez, Professor Mitchell: None. Clinical data and studies in animal models effects of medication or prefer a nonmed- have repeatedly demonstrated that ECT ication option. However, patients need to ONLINE CPD JOURNAL PROGRAM does not produce brain damage.37,38 be screened for their suitability for receiving magnetic stimulation, which includes What nonpharmacological Repetitive transcranial magnetic assessing for neuropathology, (which may approaches are recommended stimulation increase the risk of seizure) and metal for managing patients with mild Repetitive TMS generates a strong magnetic implants or fragments in the head. depression? field through a coil placed on the scalp. Magnetic fields cross the skull unimpeded Conclusion and induce electrical currents, depolarising Depression is a common presentation in neurons in the cortex. Sessions of rTMS general practice. Much distress in patients treatment take approximately 30 to 40 min- and families can be alleviated when it is utes and are typically given every weekday well managed. A stepped approach to over three to six weeks. The treatment is ­mental health care can ensure timely access nonconvulsive, does not require anaesthesia to evidence-based treatment for all those and is safe and well tolerated, with no cog- experiencing depression. The described nitive impairment.39 It is, however, clearly approach also highlights the advantages of less efficacious than ECT in the treatment e-mental health interventions as well as of patients with depression, especially newer pharmacotherapy and neuro­ depression with psychotic features.40-43 stimulation treatments. MT Although rTMS machines have been Review your knowledge of this topic approved by the TGA to treat depression References and earn CPD points by taking part in MedicineToday’s Online CPD Journal A list of references is included in the website version in adults who have failed to respond ade- Program. Log in to quately to antidepressant medication, rTMS (www.medicinetoday.com.au) and the iPad app www.medicinetoday.com.au/cpd

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MED130_Middle_Age_Lady_8_TPC_AW_OL.indd 1 17/10/11 11:25 AM MedicineToday 2015; 16(11): 16-24 Adult depression A step-by-step guide to treatment

JOSEPHINE ANDERSON BA, BMed(Hons), MMed, MHealthLaw, FRANZCP, Cert Child Adol Psych; VERONICA GALVEZ MB BS, MD; COLLEEN LOO MB BS(Hons), FRANZCP, MD; PHILIP B. MITCHELL AM, FASSA, MB BS, MD, FRANZCP, FRCPsych

References

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