Strategies and Tactics in the Treatment of Depression

Introduction

A. John Rush, M.D.
David J. Kupfer, M.D., Ph.D.

Supported in part by National Institute of Mental Health (NIMH) Center Grant MH-30915 to the Department of Psychiatry, University of Pittsburgh Medical Center and Western Psychiatric Institute and Clinic, and by the Sarah M. and Charles E. Seay Center for Basic and Applied Research in Psychiatry to the Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas. The authors appreciate the substantive and editorial critiques from Craig Nelson, M.D., and Glen Gabbard, M.D. The authors also thank David Savage for secretarial assistance, and Kenneth Z. Altshuler, M.D., Stanton Sharp Distinguished Chair and Chairman, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, for administrative support.

The authors of the previous section in this section have reviewed the evidence for the efficacy of and relative indications for specific mood disorder treatments. This empirically based knowledge is derived from groups of patients under study. However, clinicians apply that knowledge to individuals. In so doing, they confront a number of strategic and tactical issues that form the subject of this section. Some of these issues have been touched on in discussions of treatment-resistant mood disorders and the management of mood disorders associated with general medical conditions. In this section we provide strategic and tactical recommendations for the treatment of clinical depression based on available clinical research.

Depressed patients can overwhelm practitioners with both the frequency and the magnitude of their life events and/or psychosocial difficulties, in addition to the magnitude, duration, and severity of their depressive symptoms. A strategic plan with specific objectives for each step in the treatment and with assessments of how well each objective is being met may help to make treatment more efficient and effective.

It is now well accepted that the basic phases of treatment are the acute, continuation, and maintenance phases. Acute treatment aims to achieve symptom remission and restoration of psychosocial functioning (also an objective of the continuation phase). Continuation-phase treatment aims at the prevention of relapse, whereas preventing new episodes (recurrences) is the aim of the maintenance phase. Patients who do not experience recurrences or chronic depression are typically not candidates for maintenance treatment.

Acute-phase treatment begins with practitioners and patients choosing a treatment setting (e.g., outpatient, day hospital, or inpatient). Where treatment is delivered depends on factors such as 1) the imminent risk of suicide, 2) the patient's capacity to recognize and follow instructions or recommendations (i.e., adherence in the face of psychosis), 3) the availability of psychosocial resources, 4) the level of psychosocial stressors, and 5) the patient's degree of functional impairment.