Introduction
These are the approved guidelines published by the South African Society of Psychiatrists to provide an overview on treatment and management of commonly diagnosed psychiatric illnesses. The guidelines include consensus recommendations, based on peer contribution and using the international evidence based guidelines that are suitable for the local South African health service.
Please note that parts of this guideline may be out of date, an update will be published as soon as it is available.
This treatment guideline draws on several international guidelines: (i) Practice Guidelines of the American Psychiatric Association (APA) for the Treatment of Patients with Major Depressive Disorder, Second Edition;[1] (ii) Clinical Guidelines for the Treatment of Depressive Disorders by the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT);[2] (iii) National Institute for Clinical Excellence (NICE) guidelines;[3] (iv) Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Depression (RANZCAP);[4] (v) Texas Medication Algorithm Project (TMAP) Guidelines;[5] (vi) World Federation of Societies of Biological Psychiatry (WFSBP) Treatment Guideline for Unipolar Depressive Disorder;[6] and (vii) British Association for Psychopharmacology Guidelines.[7]
Major depressive disorder (MDD) is frequently associated with comorbid psychiatric and medical conditions and carries with it a high risk of morbidity and mortality. For many an initial episode of depression evolves into a recurrent and debilitating chronic illness with significant and pervasive impairments in psychosocial functioning.[8-11] The recent Global Burden of Disease Study estimated that unipolar major depression is the fourth largest contributor to the global burden of disease (premature mortality and disability).[12] By the year 2020, unipolar MDD is projected to be the second largest contributor to the global burden of disease, after heart disease.[13]
Prevalence and risk factors
MDD has a median lifetime prevalence of 16.1% (range 4.4 - 18%).[14] Twelve-month prevalence ranges from 5% to 10% in adults, with women at higher risk than men (ratio is approximately 2:1).[15-17] In South Africa, the lifetime prevalence of MDD documented in the South African Stress and Health (SASH) survey, the first nationally representative epidemiological survey of common mental disorders in South Africa,[18] was 9.8% across all age groups, with the highest prevalence (14.6%) in the Free State. The survey, conducted between 2003 and 2004 was a three-stage, area probability sample of 4 351adults of all races and ethnic groups living in households and single-sex migrant labourer group quarters in South Africa. The 12-month prevalence rate of MDD during this period was 4.9%. The aforementioned SASH study found that females were 1.75 more likely to develop MDD than males.
The age of onset of MDD is difficult to assess because the first episode is frequently mild and untreated, and may be determined retrospectively many years after first onset. MDD can begin at any age, even in childhood and adolescence, but there are two peaks, in the twenties and forties.[1,19] The mean age of onset of MDD has been estimated around the age of 30.[14] Family and twin studies have indicated that MDD is a complex genetic disorder being 1.5 - 3 times more common among first-degree biological relatives of persons with this disorder than among the general population.[20,21]
Female gender, a previous episode of major depression and a positive first-degree family history of depression are the most consistently described risk factors.
Comorbidity and consequences
Anxiety disorders are highly comorbid, occurring in about 58% of patients with MDD.[22] In addition, anxiety symptoms are highly prevalent in MDD, occurring in up to 80% of patients.[23] Studies investigating the effects of depression on health-related quality of life have demonstrated detrimental effects that equal or exceed those of patients with chronic medical illnesses, such as ischaemic heart disease or diabetes mellitus.[24-26] The most serious sequela of MDD is suicide. It has been estimated that about 50% of depressed patients make at least one suicide attempt during their lifetime.[27] It is well established that patients with mood disorders suffer a higher risk of suicide relative to the general population.[28] However, no risk factor or classification of diagnostic subtype has been shown to reliably predict suicide.[29] In a recent meta-analysis, the lifetime prevalence of suicide was estimated, on the basis of the intensity of the treatment setting. The analysis showed that clinically depressed patients who had been hospitalised for suicidality had a lifetime risk of suicide of 8.6%. Patients with affective disorders, who had been hospitalised without specification of suicidality, had a lifetime suicide rate of 4.0%. The lifetime suicide prevalence for mixed inpatient/outpatient populations was 2.2%, and less than 0.5% for the non-affectively ill population.[29] Depression also substantially increases the risk of death by cardiovascular disease.[30]
In addition to the personal suffering of individuals and their families, depression imposes significant costs on society.[31] These include both direct total healthcare costs and indirect costs (the latter have been estimated to be much higher than direct costs). Direct costs include mental health treatment costs and all other healthcare costs. Indirect costs include such varied factors as lost productivity associated with morbidity and mortality.[32] As depression is often not properly diagnosed and/or under treated,[33-36] and as it can affect many individuals at a relatively early age, the impact on cost can be cumulative over time.