2004澳大利亚与新西兰皇家精神科医师学会抑郁症治疗指南

Australian and New Zealand clinical practice

guidelines for the treatment of depression

Royal Australian and New Zealand College of Psychiatrists Clinical Practice

Guidelines Team for Depression

Background:The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Ministry of Health.

Method:The CPG team reviewed the treatment outcome literature, consulted with practi-tioners and patients and conducted meta-analyses of outcome research.

Treatment recommendations:Establish an effective therapeutic relationship; provide the patient with information about the condition, the rationale for treatment, the likelihood of a positive response and the expected timeframe; consider the patient’s strengths, life stresses and supports. Treatment choice depends on the clinician’s skills and the patient’s circum-stances and preferences, and should be guided but not determined by these guidelines. In moderately severe depression, all recognized antidepressants, cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT) are equally effective; clinicians should consider treatment burdens as well as benefits, including side-effects and toxicity. In severe depres-sion, antidepressant treatment should precede psychological therapy. For depression with psychosis, electroconvulsive therapy (ECT) or a tricyclic combined with an antipsychotic are equally helpful. Treatments for other subtypes are discussed. Caution is necessary in people on other medication or with medical conditions. If response to an adequate trial of a first-line treatment is poor, another evidence-based treatment should be used. Second opinions are useful. Depression has a high rate of recurrence and efforts to reduce this are crucial.

Key words:

Australian and New Zealand Journal of Psychiatry 2004; 38:389–407

depression, evidence-based review, treatment guideline.

These guidelines focus on moderate to severe depres-sion in adults treated by mental health professionals. Specialist clinicians should consider, but not be limited to, the treatments recommended. The extensive literature includes systematic reviews of randomised controlled trials (RCTs). Where knowledge is sparse, lower orders of evidence have been used. Other guidelines are avail-able for the treatment of depression in primary care settings [1,2] and for children [3].

Treatment should be a partnership between patient, general practitioner (GP) and mental health professional. Engaging with the person is crucial for effective treat-ment. Even when depression is severe and complicated, specialist services are involved only during the acute phase, with the GP co-ordinating the longer-term treat-ment plan.

Definitions

While transient lowering of mood is common, persist-ence is qualitatively different. Clinical depression is common, serious and treatable. Untreated, it can result in disability and even death. It tends to be episodic and of

Peter Ellis, Chair (Correspondence)

CPG Team for Treatment of Depression, Wellington School of Medicine and Health Sciences, University of Otago, Wellington, New Zealand. Email: ellis@

Received 13 February 2004; accepted 30 March 2004.