Management of moderate depression

For a patient diagnosed with moderate depression, which is defined as scoring 16 or more on the PHQ-9 scale, management follows a stepped-care model ¹,².

• Initial Management (Step 2): For mild to moderate depression, initial interventions may include low-intensity psychosocial interventions, psychological interventions, medication, and referral for further assessment and interventions ².
• Intensified Management (Step 3): For moderate depression, particularly if there has been an inadequate response to initial interventions, or for moderate and severe depression, management options include medication, high-intensity psychological interventions, combined treatments, collaborative care, and referral for further assessment and interventions ².
• Core Treatments: For more severe depression (which encompasses moderate depression), both psychological interventions and antidepressant medication are recommended ¹. Combined treatments, involving a psychological intervention alongside antidepressant medication, should be considered ¹.
• Routine Monitoring: Implement routine (sessional) outcome monitoring to regularly assess symptoms or personal and social functioning using a valid scale, informing both the patient and practitioner of treatment progress ¹.
• Specific Considerations:
  • Chronic Physical Health Problem: If the patient has a chronic physical health problem, advise them and their family/carer to be vigilant for mood changes, negativity, hopelessness, and suicidal ideation ². If the physical health problem restricts engagement with preferred psychosocial or psychological treatments, consider alternatives such as antidepressants or telephone delivery of interventions ².
  • Suicide Risk: If the patient is assessed to be at risk of suicide, take into account toxicity in overdose if an antidepressant is prescribed, limit the amount of drug(s) available if necessary, consider increasing the level of support (e.g., more frequent contacts), or consider referral to specialist mental health services ².
  • Depression with Anxiety: When depression is accompanied by symptoms of anxiety, the first priority should usually be to treat the depression ². However, if the patient has an anxiety disorder with comorbid depression, consider treating the anxiety disorder first, as this often improves depressive symptoms ².
  • Sleep Hygiene: Offer advice on sleep hygiene if needed, including establishing regular sleep and wake times, avoiding excess eating, smoking, or alcohol before sleep, creating a proper sleep environment, and taking regular physical exercise where possible ².