GuidelinesOther guideline
Summary points
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Please note that parts of this guideline may be out of date, an update will be published as soon as it is available.
- First-line treatment for mild to moderate depression should consist of psychotherapy (CBT or IPT) either alone or in combination with an SSRI, an SNRI (e.g. venlafaxine), bupropion, mirtazapine or agomelatine.
- For severe depression, always consider an antidepressant as first-line (an SSRI, venlafaxine (SNRI), bupropion or mirtazapine) in combination with CBT or IPT, or alternatively consider ECT.
- Severe major depression with psychotic features warrants a combination of an antidepressant with an antipsychotic. ECT should also be considered. Consider a combination of either a tertiary amine tricyclic antidepressant with an antipsychotic agent(either a first- or second-generation antipsychotic); an SSRI in combination with an antipsychotic; or venlafaxine in combination with an antipsychotic.
- Choice of medication should be based on patient profile, side-effect profile, medication availability, nature of prior response to medication, comorbid psychiatric and medical conditions, patient preference, potential drug interactions and cost.
- If a patient presents without comorbidities and has had a previous satisfactory response to an SSRI, consider initiating treatment with aSSRI. If a patient presents with a comorbid anxiety or pain disorder, consider initiating treatment with an SSRI, SNRI or mirtazapine.
- Monitor patients initially at least fortnightly and continue medication treatment for 4 - 6 weeks.
- If remission is achieved, continuation treatment is warranted.
- With partial responders but not full remitters, increase the dose and continue for a further 4 - 6 weeks and reassess.
- With no response, choose to: (i) switch to another first-line medication from a different pharmaceutical class; (ii) augment with any one of the following: lithium, triiodothyronine (T3), an antipsychotic agent, an anticonvulsant/mood stabiliser; or (iii) combine an SSRI with a TCA, an SSRI with bupropion, an SSRI with mirtazapine, or venlafaxine with mirtazapine.