Key points: depression
10 things you should know about treating depression
Careful differential diagnosis is crucial
Before starting treatment, it is important to distinguish depression from bipolar disorder (which requires very different treatment) and to screen for co-morbid psychiatric conditions, especially anxiety (which may not alter pharmacotherapy but can affect response and need for additional treatments) and attention deficit hyperactivity disorder (which should be treated concurrently). 
Treatment takes time to produce maximum effect
The time from clinical response to first-line treatment with antidepressants can vary from one to eight weeks. Patients who show some improvement after six weeks should continue on the same treatment for up to another four weeks before considering additional strategies. Dosage can be increased within this time frame.
The goal is remission
The aim of acute treatment is to eliminate symptoms of depression and restore psychosocial functioning, with depression score in the normal range.
Inadequate response requires further action
If a patient does not show improvement on antidepressants after 8 to 12 weeks, the first steps should be to re-evaluate the diagnosis, especially to rule out bipolar disorder and substance abuse, and verify adherence. Additional strategies can include adding psychotherapy or another agent, switching to neurostimulation treatment, or switching pharmacologic agents either within or outside the class.
Emphasize sleep, exercise and diet
It is important to emphasize positive health behaviors as these can be important to maintaining wellness. Sleep hygiene is important to focus on, and may require active planning and goal setting to achieve. Exercise can also be as helpful for mild to moderate depression as is medication. It should be discussed in a structured way, however, with a focus on at least three 20-minute blocks of activity per week that increases the heart rate and breathing. 
Discontinuation rates are high
Weight gain is one of the top reasons people stop taking their medications. It is valuable to weigh patients at every visit and treat weight gain seriously as an adverse effect. It may be the perception of weight gain associated with improvement that is an issue for example, and monitoring weight changes over time can help ensure adherence, and prevent the development of weight related illnesses. Gastrointestinal side effects are common and, in patients who are responding well, efforts should be made to manage these side effects and enable them to continue on treatment. [3,4]
Patients have difficulty accessing psychotherapy
Psychotherapy (cognitive behavioural therapy or interpersonal therapy) is recommended for both acute treatment of depression and maintenance treatment. Familiarize yourself with resources available to your patients. Computer-based and telephone-delivered psychotherapy are effective alternatives when in-person therapy is not available.
Weigh risks and benefits during pregnancy
The risks and benefits of initiating or continuing antidepressant medications during pregnancy and breastfeeding must be carefully weighed. Pregnancy can be a risk factor for depression and screening should be undertaken periodically. Antidepressants do not appear to be major teratogens and are excreted in small quantities in breast milk, though a few studies have found associations with (usually transient) neonatal complications.
Use a collaborative approach
Medical illness and depression need to be treated with a collaborative comprehensive approach. Co-morbid depression is a risk factor for poor prognosis and outcomes in patients with existing medical illnesses. Treatment of the depression should be accompanied by measures to reduce the medical illness' contribution to depression. It is important to consistently monitor for drug interactions that may increase side effects or reduce efficacy, especially given that treatment is often long term.
Don't assume that all symptoms your patient reports are due to depression
This is especially true if there is a change in presentation. Investigate to ensure a comorbid physical illness is not missed!
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