Decision to Initiate Medication Treatment

Treatment should follow a careful assessment of symptoms and course, a review of general health status, a formal diagnosis, and in some cases physical examination and laboratory testing (Depression Guideline Panel, 1993). This can usually be accomplished in one visit, especially if medically relevant history and past psychiatric and substance abuse history are available. Once a diagnosis of major depression or bipolar disorder has been made, medication treatment is usually indicated. Medication treatment should be initiated with the understanding that the choice of agent may be significantly affected by presenting symptoms and concurrent psychiatric, medical, or substance abuse diagnoses. Concomitant supportive, educational, and/or cognitive psychotherapy is usually indicated, although in severe depression or mania significant modifications in the methodology and goals of psychotherapy are usually required, and these will change over time depending on the extent and rate of clinical improvement and capacity to participate (also see, Chapter 18).

Hospitalization, once an expectation for most patients being treated for a major mood disorder, is now reserved for those situations where there is imminent risk of harm to self or others or an inability to maintain nutritional status. With the exception of mania or psychotic depression, treatment for most mood disorders can be accomplished entirely on an outpatient basis. Mania, severe psychosis, and/or suicidal intent are the most common situations in which hospitalization is usually required. Over the past 20 years, the purpose of hospitalization has undergone a major shift from a focus on definitive diagnostic evaluation and treatment to rapid stabilization and triage to an appropriate outpatient-based treatment setting.

Several situations call for initiation of medication treatment as soon as possible. These include conditions where improvement is unlikely without medication treatment, where possible harmful consequences may arise if the depression is untreated (e.g., loss of job or risk of suicide), or where relapse and recurrence are highly likely outcomes.

Medication treatment should be postponed if other treatable conditions may be responsible for the symptoms, the symptoms are very mild, the risk of harmful consequences minimal, or if the patient is strongly averse to the use of medication treatment. The most common of these situations occur when a recent life stress raises the possibility that the presenting symptoms represent a moderate to severe form of an adjustment disorder or that the depression may be secondary to medical illness, due to a side effect of medication treatment for another condition, or substance abuse. The decision to initiate medication treatment in these cases should follow one or two further evaluation meetings. Careful assessment for one of the many known causes of mania such hyper-thyroidism, stimulant or decongestant abuse, or right-sided brain lesions (Goodwin and Jamison, 1990) is particularly important in patients with a first episode of acute mania, in a patient with a unusual symptom profile, or in mania or psychotic depression with a first onset after age 40 (Depression Guideline Panel, 1993; Schulberg et al., 1998; American Psychiatric Association, 2000).

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