2.3 Herbal therapy
For patients who do not want to take traditional antidepressants, herbal therapy offers another option. A number of studies have shown that St. John’s wort is more effective than placebo for the short-term treatment of mild to moderate depression; there does not appear to be a significant difference in treatment response compared to TCAs and SSRIs. However, a multicenter placebo-controlled study showed that St. John’s wort was no different from placebo for moderate to severe depression. Based on the available information, the drug is not recommended for the treatment of major depression. The standard dose of the drug is 600C900mg/d.
It is important to keep in mind that the drug interacts with a variety of medications.
ΔWFSBP Recommendation.
Hypericum (St. John’s wort) may be a treatment option for patients with mild depression who wish to receive alternative therapies. However, education about potential side effects and drug interactions is essential, and potential drug interactions also need to be monitored.
(Level B evidence, Level 3 recommendation)
2.4 Electroconvulsive therapy (ECT)
The efficacy of ECT for major depressive disorder has been well documented, with remission rates of 60-80% and maximum response occurring after 2-4 weeks of treatment. ECT remains the most effective treatment modality for patients who do not respond adequately to pharmacotherapy.
ΔWFSBP Recommendation.
Indications for ECT as first-line treatment include: major depression with psychotic features; major depression with psychomotor retardation; patients with food refusal; other conditions requiring rapid relief of depressive symptoms (e.g., severe suicidal ideation); and limited pharmacotherapy (e.g., pregnancy). ECT may also be considered a first-line option for patients who have previously responded well to ECT and who prefer it for specific reasons.
(Level C evidence, Level 4 recommendation)
Other disadvantages of ECT include transient confusional states and cis/retrograde amnesia. Overall, ECT is a relatively safe treatment with a side effect rate of approximately 0.4% and no absolute contraindications to ECT, except for increased intracranial pressure. There is no reliable evidence that ECT can cause structural brain damage.
△WFSBP Recommendations
Before performing ECT, the physician must work closely with the anesthesiologist to conduct a thorough assessment of the patient’s physical condition. Caution should be exercised when performing treatment in patients with elevated intracranial pressure, elevated cerebrovascular fragility, cardiovascular disease (recent myocardial infarction, myocardial ischemia, congestive heart failure, arrhythmia, or pacemaker installation), abdominal aortic aneurysm, and severe osteoporosis.ECT should only be performed by an experienced psychiatrist.
(Clinical Consensus)
The use of ECT is now gradually increasing in outpatient emergency departments. The frequency of treatment tends to be every other day, 3 times a week, or 2 times a week. The cognitive impairment caused by low frequency treatment is relatively mild, but has not shown the same efficacy as high frequency. Unilateral ECT results in relatively mild memory impairment, but may be less effective than bilateral ECT for some patients. ideally, the total treatment course should aim to alleviate depressive symptoms and generally consist of 6-12 sessions, rarely more than 20.
2.5 Psychotherapy
The most intensively studied effective psychotherapies for depression include cognitive behavioral therapy (CBT), behavioral therapy, interpersonal therapy, and cognitive behavioral analysis system of psychotherapy (CBASP). However, a 2012 meta-analysis showed that the efficacy of cognitive therapy in reducing depression severity may be overestimated due to bias and random effects, while the overall benefits including remission, suicidal ideation, negative events, and quality of life are unclear.
ΔWFSBP recommends that
Psychotherapy should be considered as the initial treatment modality for patients with mild depression. Psychotherapy combined with antidepressant treatment is recommended for patients with moderate to severe depression, partial response to antidepressants, or problems with medication adherence. Individual patient preferences and the availability of psychotherapy also need to be considered when choosing a form of treatment.
(Level B evidence, Level 3 recommendation)
2.6 Light therapy
Fluorescent boxes are recommended. If not available, “natural light therapy” is recommended for patients with seasonal affective disorder (SAD): a one-hour walk outside in the morning for more than 2 weeks.
There are no absolute contraindications to light therapy, and there is no evidence that it is associated with visual or retinal damage, but patients at risk for visual problems should be counseled prior to treatment. Side effects of the therapy include visual fatigue or disturbance, headache, agitation, nausea, sedation and, rarely, mild mania or hypomania, but are generally mild and transient, and may resolve over time or with decreasing light intensity.
ΔWFSBP Recommendation.
Light therapy may be considered as one of the treatment options for SAD if implementation is possible and treatment compliance can be assured.
(Level B evidence, Level 3 recommendation)
2.7 Combination therapy
2.7.1 Sedatives/anxiolytics
ΔWFSBP recommendation.
For each patient, the combination of benzodiazepines? analogs should be carefully evaluated for potential benefits and drawbacks, the latter including sedation, psychomotor and cognitive impairment, other CNS depressive potential, dependence, and discontinuation syndromes. In general, benzodiazepines should not be used for previous or current treatment. analogs should not be used in patients with prior or current alcohol abuse/dependence. In addition, the use of benzodiazepines in depressed patients should generally be limited to 4-4 hours. should generally be limited to 4-6 weeks until the antidepressant has been proven effective.
(Clinical Consensus)
2.7.2 Sleep deprivation/awakening therapy
ΔWFSBP recommends.
Sleep deprivation therapy, especially complete sleep deprivation, can be applied alone to unmedicated depressed patients or started at the same time as antidepressants to accelerate the patient’s response to the medication. Alternatively, the therapy may be added to an ongoing antidepressant regimen to enhance efficacy.
(Level C1 evidence, Level 4 recommendation)
2.7.3 Exercise therapy
ΔWFSBP recommends.
Exercise therapy can be combined with medication to treat mild to moderate depression.
(Level B evidence, Level 3 recommendation)
2.8 Other treatments
2.8.1 Transcranial magnetic stimulation (TMS)
ΔWFSBP recommendation.
For the use of TMS for depression in a standard clinical setting, there is insufficient evidence and further research is needed.
(Level D evidence, Level 5 recommendation)
2.8.2 Vagus nerve stimulation (VNS)
△WFSBP recommendation
VNS may be a treatment option for patients who do not respond well to pharmacotherapy.
(Level D evidence, Level 5 recommendation)
2.9 Refractory depression (TRD)
Up to 50% of patients who do not respond to the first antidepressant do the same for the second treatment. TRD is defined by regulators as a full dose and full course of at least two antidepressants with conclusively good treatment adherence, but without clinically meaningful improvement.
Although many treatment non-responders improve with the treatment strategies mentioned above, there are still many patients who develop a chronic course.
It has been suggested that inadequate pharmacotherapy and unsystematic treatment regimens are associated with refractory depression. In clinical practice, refractory depression is often associated with inadequate doses of antidepressants, inappropriate length of treatment, or underutilization of treatment options. Some studies have shown that only a minority of patients with “refractory depression” are refractory in the absolute sense, and that the majority of patients with “relatively refractory depression” can be induced to improve with a rigorous treatment program, including ECT, when a new depressive episode occurs. Patients who have previously responded well to ECT may be considered for immediate initiation of ECT treatment.
Repeated non-sufficient medication may be detrimental to the patient and result in a negative prognosis. Some evidence suggests that this treatment pattern is associated with refractory depression. One study showed that each prior medication failure reduced patient response rates to new antidepressants by 15-20%. Other causes of refractory depression include “underlying bipolarity”.
3.The consolidation phase of major depressive disorder treatment
The goal of consolidation therapy is to reduce the risk of recurrent depression. It is generally accepted that this process should last for 6 months from the time of symptom resolution, but some researchers recommend extending it to 9 months. Overall, consolidation therapy should last longer than 9 months for those patients with a longer duration of previous depressive episodes. Given that residual symptoms are strong predictors of earlier recurrence of symptoms later in life, it is recommended that treatment should continue until these symptoms disappear. If residual symptoms are not completely eliminated by pharmacotherapy, a combination of psychotherapy may be considered. For depressed patients with psychotic symptoms, the duration of consolidation treatment should be longer than for those without psychotic symptoms.
△WFSBP recommendation
If a patient responds or remits to a specific antidepressant in the acute phase, it is recommended to continue the drug at the same dose during the consolidation period. If there are no further episodes during the consolidation period and the patient has a first episode, it is recommended that the antidepressant be tapered off. Patients should be monitored closely after discontinuation to ensure stability of remission. If the taper results in a recurrence of symptoms, the medication should be increased back to the original dose and continued for at least 6 months, after which another discontinuation should be attempted.