Monitoring...
Monitoring in depression is a crucial measure that must be undertaken, and can be particulalry useful in preventing extreme consequences such as self harm. It is not restricted to adverse effects of drug, but can involve more serious consequneces such as suicide.
Patients who ARE at suicidal risk
Or
<30 years old (younger prevalence of suicide in younger people)
Patients NOT
at suicidal risk
First 3 months: see patient every 2 weeks, sequentially on a more regular basis (2-4 weeks), if good response allow longer intervals
Seen after 1 week, until there’s no further risk
Initial phases of treatment
Management
After initiating antidepressant therapy, the patient should be reviewed every 1-2 weeks . Treatment must then be continued for atleast 1 month (6 weeks in the case of the elderly) before considering an alternative agent due to poor efficacy.
Prior to treatment:
A full medical history and physical examination should be considered, with specific
focus on personal and family cardiac history, including undue breathlessness,
exercise syncope or sudden death in young relatives.
An ECG is indicated if any such cardiac history or examination abnormalities are
identified.
Blood tests: FBC, U&Es, LFTs, TFTs. (B12 and folate should be considered,
particularly in the elderly and where poor nutritional state is suspected).
Clinical parameters
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Other common side effects should be enquired of at each clinical review, especially
those related to sexual dysfunction, as these problems are often not reported without
prompting.
Physical parameters
Drug level monitoring may be appropriate for TCAs when potential exists for toxicity,
(eg at high dose or use of concurrent interacting medication). ECGs should also be
considered in such cases. Drug level monitoring may also assist with assessing drug
concordance, however, the availability of TCA assays is often limited.
FBC, U&Es, and LFT should be conducted at least annually and more frequently if
clinically indicated.
Hyponatraemia is documented with most antidepressants, with clinical signs including
dizziness, lethargy, cramps, and seizures. It should be monitored for regularly (3
monthly) in those most susceptible (eg. >80yrs, previous history, reduced GFR or
associated drugs and comorbidities).
Clinicians prescribing to women of child bearing age not using contraception should
be mindful of potential teratogenic effects
Antidepressant specific.
Tricyclic antidepressants and venlafaxine - cardiac features should be monitored regularly.
MAOIs – education and monitoring of diet
Lithium - this involves pre-testing and monitoring of use
Remission
After 6 months of receiving antidepressants and after the patient is in remission, review is required.
Suicidal risk
Patients at risk of self harm or suicide, must be monitored accordingly. The flow diagram below demonstrates how this is assessed
Mild depression
Ideally, patients suffering from mild depression should attend review appointments with their prescriber. Those patients who fail to attend these appointments, should be contacted.