The 2020 update of the Royal Australian and New Zealand college of Psychiatrists practise guidelines provides a new framework for managing depressive disorders.
Key changes in the guidelines are an increased emphasis on essential actions that need to be taken.
The actions focus on promoting a healthy lifestyle and encourage focused psychological treatments.
The guidelines also focus on reacting to suboptimal treatment responses.
The MIDAS approach encompasses medication, increase , dose , augmentation, switch.
It is important to distinguish patients with transient depressive symptoms due to stressors and those with an episode of major depression which is characterised by 5 or more symptoms in a two week period.
It is also important to distinguish between patients with bipolar depression and unipolar depression as bipolar depression treatment focuses on mood stabilisers as opposed to antidepressants.
A family history of bipolar disorder should raise a high index of suspicion.
Lifestyle factors in particular poor diet, poor sleep, and lack of exercise can play a role in the onset and maintenance of a depressive episode.
The Mediterranean diet which consists of high fibre (vegetable rich ), fruit, fish and grain components has been shown to reduce depressive symptoms.
A regular wake up and sleep time aswell as avoiding excessive stimulation before going to bed can assist sleep patterns.
Aerobic exercise in particular should be encouraged in all patients.
Excessive alcohol use and substance abuse should be avoided.
Psychological treatments have fewer adverse effects however there may be demoralisation with slow progress but help patients to develop strategies to deal with adversity.
Augmentation of the antidepressant may be considered for inadequate response and is done with Lithium or atypical antipsychotics.
If increase in dose and augmentation does not work then switching to an alternative drug maybe useful . ECT remains a a safe and effective approach for non responders.
