Initiation of Treatment

Once a patient has been initiated on an antidepressant, dosing should be optimized to treat depressive symptoms to remission while minimizing side effects (Box 47-8). Patients should be monitored for improvement in their mood and their specific array of depressive symptoms. Continued use of measurement-based care tools, such as the PHQ-9 or QIDS, can aid in the objective assessment of improvement. Patients should be followed more frequently on initiation of treatment, increasing time between appointments as the patient improves. Monitoring for side effects, particularly those that patients may be reluctant to bring up spontaneously, such as sexual side effects, can improve adherence and the therapeutic alliance. Patients should also be monitored for any worsening of mood, increased irritability, impulsiv-ity, insomnia, sudden switches into euphoria, or suicidal ideation. Such symptoms may suggest bipolar diathesis, in which case discontinuing the antidepressant and changing to mood stabilizing agents may be indicated. Antidepressant doses should be increased every 2 to 4 weeks until the patient shows a response, maximum dose is reached, or side effects limit further dose changes. Antidepressant doses should

Box 47-8 Assessing Antidepressant Treatment

1. Monitor effectiveness of treatment.

2. Continue assessment of specific symptoms.

3. Assess need for further titration of medication.

4. Continue to use measurement-based care.

5. Assess any worsening of mood, increased irritability, or worsening suicidal ideation.

6. Assess adherence to medication regimen.

7. Assess for medication side effects.

8. Continue to emphasize nutrition, physical activity, and caring for self.

9. Minimize complexity of medication dosing (e.g., once daily or nightly, when possible).

Box 47-9 Discontinuation of Antidepressant Treatment

Remission of symptoms for 6-12 months.

Tapering of medications rather than abrupt cessation.

Discussion of relapse risks and early warning signs of recurrence.

continue to be pushed until remission is achieved, or the patient has undergone an adequate antidepressant trial, i.e., continuation of a therapeutic dose for at least 4 to 8 weeks (Nierenberg et al., 2000).

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