Departamentul de Psihologie Clinica si Psihoterapie

Universitatea Babes-Bolyai

Manual/Protocol Clinic MED Pentru Depresie

Managing Depression Using

 

Medication/Pharmacotherapy

 

(MED); A Brief Guide

 

To be Used Free for Research, Educational, and Training Purposes

 

Acknowledgements:

This MED manual/protocol for depression was elaborated by a team of psychiatrists (Dr. Lupu Viorel & Dr. Cosman Doina) from “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania, in collaboration with Dr. Daniel David (psychologist, principal investigator). The external consultant for the MED depression manual/protocol was Dr. Tullio Scrimali (psychiatrist), Catania Medical School, Italy.

To cite this REBT depression manual/protocol:

·         David, D., Lupu, V., & Cosma, D. (2004). MED depression manual; Managing depression using medication/pharmacotherapy. Babes-Bolyai University (BBU), Romania. 

 

      The preliminary and final Romanian versions of the MED manual/protocol for depression were used in a randomized clinical trial in Romania:

·         David, D., Szentagotai, A., Lupu, V., & Cosman, D. (2008). Rational emotive behavior therapy, cognitive therapy, and medication in the treatment of major depressive disorder: A randomized clinical trial, post-treatment outcomes, and six-month follow-up. Journal of Clinical Psychology, 64, 728-746.

      To cite the Romanian REBT manual/protocol for depression (used in Romania):

·          David, D. (ed.) (2006).  Rational Treatment. Tritonic Press. Bucharest.

·         David, D. (ed.) (2007). Clinical protocol of rational-emotive therapy for depression: The treatment of depression by rational emotive therapy. Synapsis Publisher. Cluj-Napoca.

 

The major handbooks and general MED manuals that are the background of this MED depression manual/protocol (and that should be implemented to complement and detail this MED manual/protocol) are:

·         American Psychiatric Association practice guideline for the treatment of patients with major depressive disorder. Am J Psychiatry, 2000, 157 (4 Suppl):1-45.

·         Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Second Edition, American Psychiatric Association, 2000.

 

Foreword:

This REBT depression manual/protocol is an evidence-based one, tested in a randomized clinical trial investigating the relative efficacy of rational-emotive behavior therapy (REBT), cognitive therapy (CT), and pharmacotherapy (fluoxetine) in the treatment of 170 outpatients with non-psychotic major depressive disorder (David et al., 2008). Patients were randomly assigned to one of the following: 14 weeks of REBT, 14 weeks of CT, or 14 weeks of pharmacotherapy. The continuous outcome measures used were the Hamilton Rating Scale for Depression (HRSD) and the Beck Depression Inventory (BDI); the categorical measure was SCID. In the MED condition, at 14 weeks, the response rates (HRSD<12) were 59% and the recovery rates (HRSD<7) were 50%. At six-month follow-up, the response rates (HRSD<12) were 68% and the recovery rates (HRSD<7) were 40%. No differences among treatment conditions at posttest were observed. A larger effect of REBT (significant) and CT (nonsignificant) over pharmacotherapy at 6 months follow-up was noted on the HRSD only.

 

MED DEPRESSION MANUAL

 

 

 

 

I. Therapist’s Research Guide

 

II. Therapist-Patient Interaction Guide

 

1. Aim of the Medication Depression Manual

 

2. Definitions

(a)  Depression Basics

(b)  What is Pharmacotherapy for Depression?

 

             

 

 


I. THERAPIST RESEARCH GUIDE:

1. Patients:

The present REBT manual/protocol should be used with depressed patients (e.g., who meet criteria for Major Depressive Disorder, according to the DSM-IV). In the clinical trial run based on this manual (David et al., 2008), we had some additional inclusion and exclusion criteria. Inclusion criteria included a score of at least 20 on the Beck Depression Inventory, and a score of 14 or higher on the 17-item Hamilton Rating Scale for Depression. Exclusion criteria included a number of psychiatric disorders (i.e., bipolar or psychotic subtypes of depression, panic disorder, current substance abuse, past or present schizophrenia or schizophreniform disorder, organic brain syndrome, and mental retardation). Patients who were in some concurrent form of psychotherapy, who were receiving psychotropic medication, or who needed to be hospitalized because of the imminent suicide potential or psychosis were also excluded (based on the clinical protocol of Jacobson et al., 1996).

 

2. Pharmacotherapy Intervention (20 sessions):

Patients assigned to pharmacotherapy attend one-weekly session with a psychiatrist. Initial sessions typically last about 50 minutes, whereas subsequent sessions last about 30 minutes. Treatment is focused on (1) pharmacotherapy management, which involves educating patients about medication, adjusting dosage and dosage schedules, and inquiring about and dealing with side effects, and (2) clinical management, which involves an assessment of the patient’s functioning in major life spheres, brief supporting counseling, and limited advice giving.

The medication used is fluoxetine, provided in flexible daily dosage, typically taken in the morning. Treatment protocol called for a beginning dose of 10 mg/d, which is increased to 20mg/d during week 1, and to 40mg/d by weeks 2-12. The maximum dosage allowed is 60-80mg/d. During weeks 12-14 the dosage is reduced again to 20mg/d if clinical condition allows), and then medication is continued based on standard clinical practice (however, face to face meetings were restricted to the booster sessions).

 

 

 

  

3. Medication Depression Manuals for Detailed Intervention Strategies:

·         American Psychiatric Association practice guideline for the treatment of patients with major depressive disorder. Am J Psychiatry, 2000, 157(4 Suppl), 1-45.

  • Jacobson, N.S., Dobson, K.S., Truax, P.A., Addis, M.E., Kowener, A.K., Gollan, J.K., et al.(1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64, 295–304.

·         Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Second Edition, American Psychiatric Association, 2000.

 

 

 II. THERAPIST-PATIENT INTERACTION GUIDE

 

1. Aim of the Medication Depression Manual:

The aim of this manual is to teach you about the medication treatment used to manage any depressive symptoms or depression-related problems you might experience.

Research has found that approximately 75% of patients who undergo medication will experience an improvement in their depression symptoms. This manual will teach you how to use medication to help yourself feel less depressed and more energetic, and to cope as best as you can with any symptoms you may experience. Research has shown that medication is helpful in managing emotional distress.  

 

 2. Definitions:

 

(a) Depression Basics

[This brief presentation is based on the free/public educational texts from http://www.depresion.com (© 1997-2008 GlaxoSmithKline: paragraphs 1, 3, and 4) and http://www.nimh.nih.gov/health/publications/depression-a-treatable-illness.shtml (paragraph 2)]

“Some people say that depression feels like a black curtain of despair coming down over their lives. Many of them feel like they have no energy and can’t concentrate. Others feel irritable all the time for no apparent reason. The symptoms vary from person to person, but if you feel “down” for more than two weeks, and these feelings are interfering with your daily life, you may be clinically depressed.” (GlaxoSmithKline).

“A depressive disorder is a problem that involves the body, mood, and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people who suffer from depression.” (NIH).

“Most people who have gone through one episode of depression will, sooner or later, have another one. You may begin to feel some of the symptoms of depression several weeks before you develop a full-blown episode. Learning to recognize these early triggers or symptoms and working with your therapist will help to keep the depression from worsening.” (GlaxoSmithKline).

“Most people with depression never seek help, even though most of them will respond to treatment. Treating depression is especially important because it affects you, your family, and your work. Some people with depression try to harm themselves in the mistaken belief that the way they feel will never change. Depression is a treatable disorder.” (GlaxoSmithKline).

(b)   What is Pharmacotherapy for Depression?

“Pharmacotherapy is a medical treatment involving pills (i.e., antidepressant medication). There are several types of antidepressant medication used to treat depressive disorders. These include newer medications-chiefly the selective serotonin reuptake inhibitors (SSRIs), which are used in this study too! The SSRIs-and other newer medications that affect neurotransmitters such as dopamine or norepinephrine-generally have fewer side effects than other antidepressant medication. Although some improvements may be seen in the first few weeks, antidepressant medication must be taken regularly for 3 to 4 weeks (in some cases, as many as 8 weeks) before the full therapeutic effect occurs.” (free/public educational text from NIMH: Depression).

Treatment is focused on (1) pharmacotherapy management, which involves educating patients about medication, adjusting dosage and dosage schedules, and inquiring about and dealing with side effects, and (2) clinical management, which involves an assessment of the patient’s functioning in major life spheres, brief supporting counseling, and limited advice giving.

“Patients are often tempted to stop medication too soon. They may feel better and think they no longer need the medication, or they may think that medication isn’t helping at all. It is important to keep taking medication until it has a chance to work, though side effects may appear before antidepressant activity does. Once you are feeling better, it is important to continue the medication for at least several weeks to prevent the recurrence of depression. Some medications must be stopped gradually to give the body time to adjust. Never stop taking an antidepressant without consulting the doctor for instructions on how to safely discontinue the medication” (free/public educational text from NIMH: Depression).

 

 

 

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