"What's Next for Managed Mental Health" > Page 1, 2

Kiesler's vision of tomorrow's mental health care includes the following points:

We offer the following alternative aspirational guidelines for treating depression based on our review of the scientific literature.

• Psychotherapy, notably cognitive—behavioral intervention or interpersonal psychotherapy, should be considered the treatment of first choice for depression primarily because of superior long-term outcome and fewer medical risks than drugs or combined treatment; medications, combined treatment, or another brand of psychotherapy may be considered for nonresponders after the costs and benefits have been carefully weighed.

• Clinicians should be cautious about intervening with insight-oriented psychotherapy alone because evidence suggests that this form of therapy may produce relatively poorer outcomes.

• If antidepressants are used, psychotherapy should be included because of the higher risk for relapse with medication alone.

• Whenever possible, a single medication should be used until controlled research studies have adequately evaluated the safety risks and efficacy of combined medications.

• If antidepressant medication is used, clinicians should use the lowest, safest therapeutic dose for the shortest possible duration because of side effects, cardiotoxic risks, risk of suicide, possible increased dropout rates, and scarcity of long-term outcome or risk data.

• Clinicians should be cautious about prescribing antidepressants (especially tricyclics) to hospitalized medical patients, especially those diagnosed with cardiac disease, because of high nonresponse rates, intolerance of side effects, and risk of sudden death.

• Clinicians should be cautious about prescribing antidepressants (especially tricyclics) to acutely suicidal patients because of the danger of serious overdose.

• Clinicians should not prescribe antidepressants to children or adolescents because there is no evidence that these medications are effective with children or adolescents and little is known about the health risks for young people.

• Caution should be used in prescribing antidepressants to elderly people as a result of increased risks of anticholinergic side effects and hypotension.

• Clinicians should avoid the use of regular minor tranquilizers alone, which have resulted in worse outcomes than no depression treatment at all.

References:

Antonuccio, David O., Danton, William G., & DeNelsky, Garland Y. Psychotherapy Versus Medication for Depression: Challenging the Conventional Wisdom With Data Professional Psychology: Research and Practice. December 1995 Vol. 26, No. 6, 574-585.

Jacobson, Neil S.  Cognitive-Behavior Therapy Versus Pharmacotherapy: Now That the Jury's Returned Its Verdict, It's Time to Present the Rest of the Evidence.  Journal of Consulting and Clinical Psychology February 1996 Vol. 64, No. 1, 74-80.

Karon, Bertram P. & Teixeira, Michael A.  "Guidelines for the Treatment of Depression in Primary Care" and the APA Response, American Psychologist June 1995 Vol. 50, No. 6, 453-455

Schulberg, Herbert C. Clinical Practice Guidelines for Managing Major Depression in Primary Care Practice Implications for Psychologists,  American Psychologist January 1994 Vol. 49, No. 1, 34-41

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