Common Mental Disorders Depression - New Zealand Doctor

Chapter 6 Management of depression in adults/pakeke
Atypical depression
Atypical depression generally presents with symptoms such as over-eating and oversleeping.
The patient may report that their mood improves in response to positive
events, and the mood disorder may be preceded by a longstanding sensitivity
to rejection. 243 Compared to other patients with depression, those with atypical
depression are more commonly female, with younger age of onset and a more severe
degree of psychomotor retardation, which can be described as ‘leaden paralysis’. 65
Treatment with an SSRI is appropriate. If the patient does not respond to an SSRI and
has significant functional impairment, they should be referred urgently to secondary
care mental health services for consideration of other strategies. 65
6.2 Prevention of relapse or recurrence
Ongoing strategies are needed to reduce the risk of relapse or recurrence of
depression. Many patients do not receive adequate follow-up after treatment and do
not persist with ongoing preventive measures, 338 partly because primary care models
tend to emphasise acute care and rely on patient-initiated follow-up.
Chronic disease management models have shown the effectiveness of relatively simple
interventions, such as ensuring regular follow-up during treatment, proactive ongoing
telephone follow-up of patients at risk, support for self-management, and relapseprevention
planning after recovery from an acute episode. 142
Adults/pakeke taking antidepressants should normally continue to take them for at
least 6 months after remission of a first episode of depression as this greatly reduces
the risk of relapse. 354 After a second or subsequent episode, antidepressants should
be continued for at least 2 years. 9 Maintenance therapy needs to address not only the
issue of how long the person should continue taking antidepressants but also what other
nonpharmacological strategies are necessary for this individual. 277 Various psychological
therapies (such as CBT, behavioural therapy [BT], interpersonal psychotherapy
[IPT] and mindfulness-based cognitive therapy) either alone or in combination with
antidepressants, have been shown to reduce the long-term risk of relapse. 334,335,355-357
The relevant studies delivered therapy in a variety of formats, ranging from 8 sessions
weekly, 335,355 to 16 sessions over 20 weeks plus ongoing booster sessions. 357
Once the patient has recovered from an acute episode and before he/she is
discharged, the practitioner should discuss with the patient the need to be vigilant for
early indications of relapse. 358 The patient should be strongly encouraged to continue
with preventive measures, such as maintaining lifestyle changes and complying with
maintenance therapies. Early warning signs and triggers of possible recurrence should
be discussed and the patient should have planned in advance what steps to take,
if necessary. 142 Appendix F: Self-management Resources includes a web address for
Identification of Common Mental Disorders and Management of Depression in Primary Care 79