At the end of last year, a comprehensively revised version of the S3 guideline on unipolar depression, first published in 2009, was published. What are the most important changes? What is the role of the primary care provider? How should we care for specific patient populations, such as immigrants with depression, elderly patients, or pregnant women? We have summarized some important changes.
Of particular relevance to primary care providers in the guidelines is the chapter on low-threshold psychosocial interventions. These are described in more detail for the first time. Particularly in the English-speaking world, there has recently been an increase in studies reviewing the effectiveness of these methods for depression.
A distinction can be made between guided self-help and technology-based interventions (a combination is also possible). The former does not mean attendance at self-help groups, but rather the use, supervised by a physician, of self-help manuals and books derived from evidence-based interventions (usually cognitive behavioral therapy) and created specifically for this purpose. This corresponds most closely to the German-language term “bibliotherapy.” In studies, this type of intervention is usually conducted over three sessions, with a maximum of six. Contact with the expert is therefore limited, restricted to monitoring progress and results, and has an overall supportive character. This requires a certain competence in dealing with such texts on the part of the patient. On the other hand, this makes it easier to promote understanding and knowledge of the disease among relatives.
Technology-based services include telephone or computer/internet-based interventions. In particular, computer-based cognitive behavioral therapy has been studied and validated to date. This is a structured help program, similar in content to conventional behavioral therapy, but delivered primarily via CD-ROM, DVD, or the Internet. Therapeutic contact is limited to a program introduction, brief monitoring, reminder/reinforcement feedback, and the option for further consultation. Extensions to cell phones are also possible. These measures can also be used as augmentation of a therapist-assisted program. The variability of the individual electronic programs is great.
The family doctor has an important coordinating role with regard to the consultation and implementation of these measures. Although the guideline does not provide specific recommendations for the use of these procedures, it does list numerous studies that suggest a positive effect of the interventions.
Psycho- and pharmacotherapy in the elderly
The new guideline is the first to specifically address the needs of older patients, who are often seen as problematic for psychotherapy. The reason for this is the high dropout rates due to typical age-related problems (transportation during immobility, somatic comorbidities, sensory impairments, etc.). However, the authors emphasize that there are now age-specific adaptations of the therapy manuals as well as care services for people with mobility impairments, e.g., the aforementioned Internet-based interventions. Therefore, psychotherapy should also be offered to older persons aged 65 years and older (recommendation grade A). In severe forms, the combination with pharmacotherapy is recommended (B). Also in this group of patients, cognitive behavioral therapy has the most extensive and certain evidence, next to problem-solving therapy. The quality of the randomized controlled trials considered is good to very good. In cases of mild cognitive impairment and depression in old age, psychotherapy should preferably be offered as individual therapy (B).
With regard to pharmacotherapy, older patients can in principle be treated in the same way as younger patients, but with special consideration of side effects or tolerability. For tricyclics, choose a lower starting dose (0).
Patients with migration background – different understanding of disease and therapy
According to the guideline, for patients with a migration background, it is useful to include culture- or country-specific rituals and techniques (e.g. mediation) in the treatment. If available and desired by the patient, these can be specifically promoted in the sense of individual resources. Knowledge of socioculturally shaped ideas about illness and medicine also plays a crucial role in anamnesis and diagnostics, otherwise there is a risk of misdiagnosis and inadequate treatment (in cultures with holistic mind-body concepts, for example, psychological complaints are expressed primarily in physical terms).
Specific health risks related to migration itself should also not be forgotten (more critically relevant life events, precarious work/housing situation, social exclusion, unstable social fabric, pressure to assimilate, etc.). If such migration-specific factors are integrated into the therapy and disease concept, this can result in participatory decision-making and, consequently, increased adherence. In cases of language limitations, nonverbal therapies (artistic, occupational therapy) can supplement the services offered and provide a way to express and address emotional issues. However, evidence in this area is not yet available.
What are the benefits of exercise?
Another topic of the new guideline are the recommendations on physical training and sports. With recommendation grade B, the authors advise that patients with a depressive disorder and no contraindication to exercise should receive structured and supervised physical training. However, neither the most effective type of training nor the optimal duration/intensity for the treatment of depression has been sufficiently clarified scientifically. This is not least due to methodological problems in data collection (blinding with regard to physical activity hardly possible; control of conditions in the comparison arm difficult) and consequently to the great heterogeneity of the studies. Larger randomized-controlled trials and several meta-analyses suggest at most a moderate effect of physical activity on depression (exclusively during the intervention phase). Thai Chi or Qigong also seem to have positive effects on depressive symptoms.
Depression during pregnancy
There is a completely new chapter on pregnancy (“Depression in the Peripartum Period”). These include antepartum and postpartum depression. For ethical reasons, no randomized-controlled trials exist on potential harms from medication use in the peripartum period. The evidence comes from naturalistic comparative studies and case reports. Most studies of potential risks consider SSRIs, followed by tricyclic antidepressants (TCAs). There are few findings on newer classes of agents and, accordingly, no clear assessment of the risks.
Overall, the risk-benefit assessment in pregnancy and lactation must be made very carefully. In any case, psychotherapy should be offered for depression during pregnancy (B). If the decision is made to use pharmacotherapy, monotherapy should be given at the lowest effective dose, with regular monitoring (aim for low effective drug levels) and without abrupt discontinuation. Fluctuating drug plasma levels during pregnancy should be considered (0).
Paroxetine and fluoxetine should not be represcribed as first-line agents in pregnancy because of the small risk for malformations (0). Because of possible teratogenicity and risk of postpartum complications, patients with planned pregnancy should not be readjusted to a lithium drug (only in individual cases and after being informed of the risks) (0). If a decision is nevertheless made to treat with lithium (e.g., continuation of therapy in the case of a high risk of relapse/suicide), the dose should be distributed over several intakes per day in order to achieve a lithium level in the lower therapeutic range. The drug level must also be checked frequently in pregnant women. Sertraline or citalopram do not appear to be associated with an increased risk of structural malformations. However, sonographic fine diagnosis of the fetus is advised at the 20th week of gestation.
For patients at increased risk of depression, e.g., with previous depressive episodes, psychotherapy or psychosocial intervention should be offered antepartum or postpartum (recommendation grade A). Psychotherapy is also indicated for already manifest postpartum depression (A). A possible option for pharmacotherapy in moderate/severe postpartum depression is SSRIs and TCAs, again, of course, only after careful risk-benefit consideration (0).
Physical training may improve symptomatology in both depression during (B) and after pregnancy (0) as a complementary measure.
Increased risk after stroke
A new Grade B recommendation is found on the (significantly increased) risk of depression after ischemic or hemorrhagic stroke. Patients should not receive standard antidepressant prophylaxis unless they currently have a diagnosis of a depressive episode. This is due to reports of an increased incidence of cerebrovascular events with therapy. Regular monitoring for depressive syndromes is preferable. In manifest poststroke depression, pharmacotherapy with nonanticholinergic agents comes into play (B)-empirical evidence exists for fluoxetine and citalopram.
Source: DGPPN, et al: S3-Leitlinie/Nationale Versorgungsleitlinie Unipolare Depression. Long version. 2nd edition, version 1. November 2015.
HAUSARZT PRAXIS 2016; 11(3): 44-46
