Clinical Guidelines for the Treatment of Depressive Disorders

II. Principles of Management

Robin T Reesal, MD, FRCPC1, Raymond W Lam, MD, FRCPC2,
and the CANMAT Depression Work Group3

Background: The Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments partnered to
produce clinical guidelines for psychiatrists for the treatment of depressive disorders.
Methods: A standard guidelines development process was followed. Relevant literature was identified using a computerized
Medline search supplemented by review of bibliographies. Operational criteria were used to rate the quality of scientific evidence, and the line of treatment recommendations included consensus clinical opinion. This section on Principles of Management is 1 of 7 articles drafted and reviewed by clinicians. Revised drafts underwent national and international expert peer
review.
Results: The principles and goals of psychiatric management with psychotherapy and pharmacotherapy are reviewed. Two
phases of treatment, acute and maintenance, are identified. Special topics, including inpatient management, suicide management, and medical-legal issues are also discussed.
Conclusions: These principles of psychiatric management provide a framework for the use of specific treatments for depressive
disorders.
INTRODUCTION

hide behind a substance-abuse problem or anxiety disorder,

and, over time, can develop into a bipolar disorder. The components involved in making a diagnosis and setting up a treatment plan are complex and constantly changing. Hence, the
diagnosis and treatment plan should accommodate and adapt
to new information as it becomes available.

his section offers an overview of principles for the management of major depressive disorder (MDD). These involve assessment and formulation, psychiatric management,
principles of psychotherapy and pharmacotherapy, and special considerations such as suicide, inpatient management,
and medical-legal issues.

2. What are the phases of treatment?

In recent years, major depression has come to be considered a
chronic and/or recurrent, rather than an acute, illness (3). This
reevaluation of the disorder has inherent treatment implications because patients with major depression tend to exhibit
episodic recurrence and/or chronic residual symptoms.

1. What are the principles of diagnosis?

The cornerstone of any treatment plan is a proper diagnosis.
While knowledge of psychopathology and diagnostic criteria
are essential, the clinician should also understand the context
of the symptoms in terms of the biological, psychological,
and social factors that make up a case formulation (1,2). Also
important is an understanding of the relevant predisposing,
precipitating, and perpetuating factors that can help identify
impediments to the treatment plan. To depend only on a
patients history without obtaining collateral information
when it is available increases the risk for erroneous conclusions.

The course and treatment of depression have been traditionally defined in terms of response, remission, relapse, and recurrence (4). Response is defined as a significant reduction of
depressive symptoms to a level below the threshold for MDD,
whereas remission is considered a resolution of depressive
symptoms or a return to wellness. A relapse is defined as an
exacerbation of depressive symptoms that occurs during the
same episode of depression; that is, within 6 months after the
patient has achieved remission. A recurrence is considered a
new depressive episode occurring after a 6-month remission
period. The treatment of major depression has been typically
divided into 3 sequential phases: acute phase (to achieve response), continuation phase (to prevent relapse), and maintenance phase (to prevent recurrence) (5).

There are several reasons why a diagnosis, once made, should

always be under review. Major depression can have multiple
etiologies, can mimic such other conditions as dementia, can

Medical Director, Centre for Depression and Anxiety, Calgary, Alberta.

and Head, Division of Mood Disorders, Department of Psychiatry, University of British Columbia,Vancouver, British Columbia.
3 The members of the CANMAT Depression Work Group include Sidney H
Kennedy (co-chair), Raymond W Lam (co-chair), Murray W Enns, Stanley P
Kutcher, Sagar V Parikh, Arun V Ravindran, Robin T Reesal, Zindel V
Segal, Lilian Thorpe, Pierre Vincent, and Diane K Whitney.

2Professor

While these operational definitions may have heuristic value,

in practice it is often difficult or impossible to ascertain for a
particular patient whether a return of symptoms is a relapse or
a recurrence. As well, the concept of continuation treatment is
based in part on responses to antidepressants, which may not
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CLINICAL GUIDELINES FOR THE TREATMENT OF DEPRESSIVE DISORDERS

be similar to responses to psychotherapies. Hence, unitary

concepts that combine relapse/recurrence definitions and
continuation/maintenance phases are more relevant and applicable to the clinical situation. The management of depression can there fore be di vided into the acute phase
(suppression of symptoms to clinical remission), lasting 8 to
12 weeks, and the maintenance phase (prevention of relapse/recurrence), lasting 6 months or longer.
3. What are the clinical principles for psychiatric
management?
Before treatment is instituted, consent should be obtained.
For the consent to be valid, certain criteria must be met (6,7).
Patients need to be competent and must understand what is involved with their consent. An explanation of the risks and
benefits of the proposed treatment and alternative treatments
must be supplied. The consequences of refusing treatment
should also be discussed. A notation should be made in the
patients chart indicating that voluntary consent was obtained
to proceed with treatment.
A good psychiatristpatient relationship is crucial to the success of any treatment plan for depression. This relationship
should be based on trust and collaboration, and the role of
each participant should be clearly defined. Several terms have
been used to describe this relationship between the clinician
and the patient, such as working alliance, therapeutic
bond, and therapeutic alliance (810). A good working alliance, as reported by the patient, has the strongest relationship to outcome, implying that the patient is comfortable with
the clinician, that there is agreement about treatment goals,
and that the treatment procedures are seen as appropriate and
acceptable. The alliance is considered a strong positive predictive factor of treatment outcome in the psychotherapies,
regardless of the specific treatment (11,12). Moreover, a
strong therapeutic alliance is also associated with reduced
symptom severity, improved patient functioning, and improved compliance with pharmacotherapy (1315).
In addition to providing a caring, compassionate, and nonjudgmental environment for treatment, the acute phase of
treatment should include psychoeducation. Psychoeducation
includes the illness concept of depression, the expectation for
response (that is, instillation of hope), and the need for adherence to the treatment regimen. There should be discussion
about how the diagnosis was made, the implications of having
the condition, how it may affect the patients social and work
life, the course of the condition, and the treatment options. Patients should be educated about their roles and responsibilities in the treatment processto at tend appoint ments
regularly, to ask questions, and to indicate when they cannot
adhere to treatment. They need to understand that their motivation to improve is crucial. Family members (for example,
spouse or parent) can be valuable allies to offer support and to
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Vol 46, Suppl 1

promote adherence to treatment. Frequent contacts during the

acute phase, even if these are brief, weekly telephone progress reports, will enhance the therapeutic alliance.
A patients treatment often involves a team of health professionals. The psychiatrist is responsible for maintaining contact with the referring family physician, and, in many cases,
there will be sharing of care for patients (16). Consultation
notes should specify the diagnosis and treatment plan and the
roles of other professionals involved in treatment. The psy chiatrist should also document visits and treatments provided, including details of prescribed medications. There
should be regular communication between the psychiatrist
and other health providers involved in the patients care, especially about changes in medication status. Copying progress notes to other health care professionals enhances this
communication (17). E-mail can also be used to enhance
communication among psychiatrists, patients, and other professionals, although confidentiality issues must be recognized and addressed (18).
4. What are the goals of treatment?
Goal setting provides the road map for the treatment plan. It
ensures that both patient and psychiatrist are aiming for the
same outcome and following the same timeline (19). Inappropriate expectations can lead to patient and/or family discontent over psychiatric treatment.
The goals in the acute phase of treatment for the patient with
depression are to reduce symptoms and improve quality of
life (response and remission). The goal for the maintenance
phase of treatment is to prevent return of depressive symptoms (relapse/recurrence). The presence of residual symptoms is increasingly recognized as an important predictor of
relapse and recurrence (20). The acute-treatment goals
should therefore include full remission of symptoms and return to premorbid social function. The use of psychiatric rating scales, such as the Hamilton Depression Rating Scale
(HDRS) (21,22), the Montgomery-Asberg Depression Rating Scale (MADRS) (23), and the Beck Depression Inventory
II (BDI-II) (24), can be useful in monitoring symptom
change.
By setting timelines to achieve goals, the treatment plan can
be regularly reviewed. Most treatments should lead to some
clinical improvement within 4 to 8 weeks. If there is limited
response after that time, a change in the treatment plan is indicated (see Section III and Section IV for a discussion of psycho ther apy and phar ma co ther apy; see Sec tion V for
combining psychotherapy and pharmacotherapy). Restoring
social function may require other types of rehabilitative services, including psychotherapy, occupational therapy, career
counselling, and marital or family therapy. Monitoring
change in social function can include scales such as the

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II. Principles of Management

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Table 2.1 Models of psychotherapy and putative mechanisms of change

Psychotherapy model

Putative mechanism of change

Cognitive-behavioural therapy (CBT)

Challenging and changing negative cognitions alters the way that individuals construe their interpersonal
world and promotes more adaptive patterns.

Interpersonal psychotherapy (IPT)

Improving the quality of relationships and addressing socially avoidant patterns allows individuals to
benefit from the stimulation and validation of social interaction.

Brief dynamic psychotherapy (BDP)

Identifying and discussing internal conflicts, often around dependence and intimacy, frees individuals to
more effectively make choices in how to conduct their lives.

Supportive psychotherapy (SPT)

Improving immediate adaptation to the current life situation through the conscious process of learning
problem-solving skills reduces stress and builds self-confidence.

Cognitive-behavioural analytic system of

psychotherapy (CBASP)

Understanding how individuals create their own difficulties, especially in relationships, allows them to
alter the situations that make them unhappy. This model was specifically designed for patients with
chronic depression.

Global Assessment of Functioning (GAF) (25) or similar

measures (26).
5. What are the clinical principles for psychotherapeutic
management?
The contemporary research on psychotherapy for depression
has focused on several specific models of psychotherapy;
each has its own unique putative mechanisms of action and
strategies for promoting change (Table 2.1). A large number
of other labels have been created for other types of psychotherapy, but there is considerable overlap of strategies and
common threads winding through the different models. In
particular, the role of the working alliance has been emphasized as the single most important ingredient.
Canadian guidelines for psychotherapy in psychiatry have recently been proposed (6,27). As noted in these guidelines,
there is a discrepancy between the research concern with specific models of psychotherapy using treatment manuals and
the relatively few clinicians who have been specifically
trained in their use. Recent additions to resident training
guidelines are designed to address this situation (28). Modest
evidence indicates that closer adherence to a particular model
produces superior outcome results in clinical trials of psychotherapy. The limitation of these trials, as with pharmacotherapy trials, is that the patients included in the studies may not
represent those treated in the community because of selection
biases (for example, excluding comorbidity). The understanding that forms the basis for psychotherapy is derived
from theoretical concepts and the clinicians own orientation
and training (6). Hence, in the clinical practice of psychotherapy, as in pharmacotherapy, clinicians may still at times deviate from guidelines or manuals in the best interests of their
patients, even though there may not be empirical support.
Outcome data indicate that the specific manualized psychotherapy models, such as cognitive-behavioural therapy
(CBT) and interpersonal psychotherapy (IPT), have approximately similar outcome for the treatment of MDD of

moderate severity (see Section III). The rates of response to

these treatments are similar to the rates for medications, although pharmacotherapy may have an earlier effect, especially on such nonspecific symptoms as anxiety and sleep. On
the other hand, psychotherapy may promote an earlier sense
of alliance and therefore serve to keep patients from terminating early. Patients with a treatment-resistant or severe history
are likely to have lower response rates to psychotherapy.
Most of the reported studies have used time-limited models of
12 to 20 sessions. These time-limited models place a strong
emphasis on the early identification of specific core issues
that need to be addressed. Each of the models has a specific
technique for assessment decisions regarding the selection of
focus areas. It is important that the clinician and patient agree
that these should be the treatment goals. Often these are written in the form of target goals that can be rated periodically
throughout the course of psychotherapy. Treatment then focuses persistently on these targets. This active-focusing technique is at the heart of all the models, with the expectation
that, if the goals have been properly selected, the process of
addressing them will be necessarily anxiety-promoting and
the subject of occasional resistance. An important goal is that
the patient will have an increased sense of mastery from being
able to address and achieve personal objectives.
Patients who have not begun to respond to psychotherapy
within 2 months are less likely to have a full response later. At
6 months, therapeutic strategies and outcome can be reviewed
to determine whether formal psychotherapy should continue.
If the patient is not showing response within the anticipated
time frame, changing the treatment modality (for example,
switching to a different psychotherapy model; switching to,
or adding, pharmacotherapy) should be considered or a second consultation opinion obtained.
Combined psychotherapy and pharmacotherapy is reported
in psychiatrist utilization surveys to be the predominant treatment model. Unfortunately, the mode of psychotherapy is not
usually defined. Some comparative studies have found a synergistic effect with the combination of medication and CBT
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CLINICAL GUIDELINES FOR THE TREATMENT OF DEPRESSIVE DISORDERS

or IPT (see Section V). Other studies, however, have found

minimal benefits in combined treatment, compared with single treatment, perhaps because psychotherapy and pharmacotherapy are each quite effective for MDD. Combined
treatment has never been found to be less effective than
monotherapy.
Selecting a psychotherapy remains a clinical challenge. Recent studies have indicated that specific patient characteristics may predict better outcome with specific models. For
example, psychological mindedness is correlated with better
outcome in both dynamic and supportive psychotherapy
(29,30). Quality of object relations (QOR) can predict outcome between dynamic and supportive psychotherapy: patients with high QOR do better in the dynamic model, and
those with low QOR do better in the supportive model (31).
Perfectionistic patients experience more stress during therapy and are more likely to drop out (32). More research in this
area is required to help clinicians make decisions about the
type of psychotherapy to offer to different kinds of patients.
6. What are the clinical principles for medication
management?
The ideal antidepressant should have rapid onset of action, effectiveness in short- and long-term treatment, a wide thera peutic dose range, and minimal drugdrug interactions
safety. It should also be safe in overdose, nonaddictive, costeffective, and easy to use (33). Unfortunately, this antidepressant does not exist. Therefore, when choosing an available
antidepressant, factors such as the severity of the episode, the
patients age, the patients ability to comply, the suicide risk
and impulsivity, previous response and tolerability to antidepressants, the presence of comorbid psychiatric or medical
disorders, and the use of concomitant medications need to be
considered.
Knowledge of pharmacology, including the pharmacokinetics and pharmacodynamics of the drugs, is essential to pre scribe antidepressants and to interpret clinical issues that may
arise (see Section IV). Of importance is the potential for
drugdrug interactions (see Section IV) and the role of serum drug-level monitoring for medications that have a therapeutic window, such as nortriptyline or lithium (33).
When prescribing an antidepressant, the psychiatrist should
discuss the following issues with the patient: alternative treatment options, why the agent is indicated, short- and long-term
side effects, possible drug interactions, what to do if there is
clinical deterioration, and how to manage anticipated side effects. Birth control and pregnancy issues should also be re viewed with women.
Clinical management (CM) is an important component of
pharmacotherapy (34,35). CM includes brief sessions of
psychoeducation and supportive strategies. Patients should
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Vol 46, Suppl 1

learn that the physiological symptoms of depression might

improve before they subjectively sense improvement (hence,
a rationale for objective reports from a family member).
Symptom improvement (that is, response) may not occur until after 2 to 4 weeks on an adequate dose of medication, and
remission often takes 2 to 4 months of treatment. Reviewing
the fact that recovery is typically a sawtooth curve, rather
than a linear progression, may reassure the patient/family
when a few bad days occur. Patients should be aware that side
effects are usually transient and that they should not stop
medications, even if they are feeling better, without discussing it with their doctor. Finally, patients can be given the opportunity to call with questions and concerns, especially
about side effects. These simple explanations and directions
about drug treatment can greatly enhance adherence to medications (36).
During the maintenance phase after remission of acute symptoms, all patients should continue the antidepressant dose that
induced remission for at least 6 months. The relapse rate is
35% to 60% if antidepressants are discontinued in the first 6
months, compared with 10% to 25% in patients who continue
medications (37,38). The risk of relapse is particularly high if
drug discontinuation occurs in the first few months of response/remission.
Regular, but less frequent, office visits (for example,
monthly) in the maintenance phase will continue to enhance
the therapeutic alliance and promote treatment adherence.
Physicians should be attentive to later-onset side effects (for
example, weight gain, cognitive dulling, sexual dysfunction)
and suggest treatment interventions (19). The financial cost
of newer medications may be prohibitive for some patients
and is an often-unrecognized cause of treatment discontinuation. At this time, it is appropriate to review the early-warning
signs of relapse with patients and their families, along with
potential courses of action. Similarly, clinicians should address interventions for other comorbid disorders/problems
(for example, substance abuse, marital/family strain) that
may increase the risk of relapse.
Some patients will require a longer period of maintenance antidepressant treatment (that is, 2 years or longer) because they
have risk factors for recurrence of depression. These risk factors include 3 or more lifetime episodes of depression, frequent episodes (for example, 2 or more episodes over a 5-year
period), chronic episodes, and older age (39 41). The decision for continued maintenance treatment should also include
discussions with the patient/family about the rapidity of onset, severity/disability, the degree of difficulty treating past
episodes, and the ability of the patient to recognize symptoms
of relapse and to seek treatment. Any decision to stop treatment should be a collaborative decision between physician
and patient, with ongoing monitoring for relapse. When
medication is to be discontinued, the dose should be tapered

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II. Principles of Management

Table 2.2 General risk factors for suicidea

Presence of anxiety, agitation, and panic attacks
Persistent global insomnia
Anhedonia and poor concentration
Feelings of helplessness and hopelessness
Impulsivity
Substance abuse
Men between age 20 30 years and over age 50
Women between age 40 60 years
Older age
Previous suicide attempts
Family history of suicidal behaviour
a

Adapted from (44) (69) (70).

over several weeks, which will lessen the risk of a discontinuation syndrome (42) and may lessen the risk of relapse.
7. What are the clinical principles for suicide
management?
People with MDD, of all the psychiatric conditions, are at
highest risk of suicide (43,44). Between 40% and 60% of
completed suicides involve patients with depression, and all
such patients should be assessed regularly for suicide risk.
General risk factors for suicide in depression are included in
Table 2.2.
Questions a clinician should ask in evaluating suicide risk include whether the patient feels desperate, hopeless, helpless,
or is tired of struggling with life. Has the patient not wanted to
go on living? Is there active suicidal ideation? How strong are
the thoughts? How frequent, persistent, and irresistible are
they? Is there a plan? Do the means and opportunities exist?
How impulsive is the patient?
Psychosocial issues that are precipitating or promoting suicidal ideation need to be identified. Have there been recent life
events or an accumulation of events such as job loss, death of
a loved one, changes in health, or a move? Is there evidence to
indicate that the patient may feel trapped by life events, with
suicide being the only option? Are there indications of tying
up loose ends, such as making a will? Does the patient have a
sense of the future? Is there regret over the failure of a previous suicide attempt? Intense emotions of rage, shame, humiliation, loneliness, and self-hatred may also indicate a
severe depression with poor impulse control and impaired
judgmenta situation of high risk for suicide (45).
The more reasons patients with depression identify for living,
the less likely they are to act on their thoughts of suicide during vulnerable times (46). Suicide contracts, however, are unreliable: for example, 25% of suicides in the National
Institute of Mental Health (NIMH) Collaborative Study on
Depression had suicide contracts with their caregiver at the
time of the suicide (47). Such contracts are usually only effective for short periods where there is a strong therapeutic

25S

alliance; they are less reliable in the presence of poor social

support and strong suicidal urges.
Treatment of the patient with suicidal depression needs to be
aggressive (48). Safety must be ensured, medication treatment optimized, and psychosocial factors addressed. Patients
should be seen more frequently and community support systems mobilized. Firearms should not be available in the
home. Medications with a wide safety margin in overdose,
such as selective serotonin reuptake inhibitors (SSRIs) and
other newer antidepressants, should be considered. The prescriptions should be checked to ensure that lethal quantities of
medications are not dispensed. Hospitalization may be necessary for the patient with suicidal depression (49). Voluntary
admission is preferred, but involuntary admission may be required. Frequent reevaluation of suicidality is important,
even if the patient is hospitalized.
The unpredictability of suicide means that, despite best efforts, suicides will still occur during psychiatric management
(50). Postsuicide management should include contacting
families and referring to available resources to help them deal
with their loss. Survivors of a suicide are at high risk for suicidal behaviour themselves (44). Critical-incident debriefing
strategies (for example, immediately scheduling a meeting to
ventilate shock and distress) can help health care providers
deal with suicides and other traumatic events (51). Ongoing
support and counselling should be available for caregivers
following a suicide. A quality-assurance review and/or psychological autopsy should be conducted later to review any
management issues and recommendations (50,52).
Recommendations for Psychiatric Management
Start with a comprehensive evaluation of the patient.
Assess suicide risk at every evaluation.
Aim for full remission of symptoms and return to baseline psychosocial function.

Plan 2 phases of treatment:

acute phase (812 weeks) to achieve remission of symptoms,
maintenance phase (at least 6 months, but often longer) to
prevent relapse/recurrence.

Monitor response using validated outcome measures.

Reevaluate treatment at least every 4 weeks if there is no response.

8. What are the clinical principles for inpatient

management?
There are several indications for inpatient treatment of patients with depression. These include concern for the safety of
others or the patients themselves, crisis intervention, diagnostic evaluation (especially with comorbid medical or psychiatric conditions), poor response to outpatient treatment, rapid
deterioration or marked severity of depression (including
hopelessness, suicidal ideation, or psychotic features), inability to function at home, and breakdown of social supports.
Inpatient management of depression is complex and multifaceted. There are 3 overlapping phases for inpatient

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CLINICAL GUIDELINES FOR THE TREATMENT OF DEPRESSIVE DISORDERS

management of the patient with depression: assessment,

treatment, and discharge (53). The assessment phase identifies relevant precipitating factors that led to the admission
(why does the patient need hospitalization now?) and perpetuating factors that might hinder response. Physical status
is evaluated through history, physical exam, and ancillary
testing. Frequently, the psychiatrist involved in inpatient
treatment is different from the psychiatrist caring for the patient in the community. Therefore, communication between
hospital and community care is essential; collateral information should be obtained from family and community-based
health care providers, including the family physician. Written
reports can be obtained with appropriate patient consent.

Vol 46, Suppl 1

In Canada, there is increasing pressure to reduce the length of

stays for patients with depression, in part because of scarce
hospital resources (55). Day-hospital or transitional programs play an important role in discharge planning, because
patients require a greater level of care upon leaving the hospital than in the past (56). It is often valuable if the patient can
meet with the day-hospital staff or outpatient follow-up before discharge. The period after discharge is also a high-risk
time for suicidal behaviour, so close monitoring of discharged patients is warranted.

Recommendations for Inpatient Management

An evaluation of dangerousness and the level of care required

should be an early priority. For suicidal patients, the psychiatrist must determine the need for one-on-one monitoring or its
equivalent (for example, a secure observational unit). Hanging and asphyxiation are possible if an observer is away for as
little as 15 minutes (54). Ensure on admission that the patient
understands the rules of the unit and the roles of the team
members. A diagnosis and treatment plan, with specific objectives, is set in collaboration with the patient.
In the treatment phase, both medication- and psychotherapybased treatments are implemented. Family or relationship issues can be addressed by meeting with the individuals involved, if necessary. Workplace stressors, disability, legal,
and education issues can be explored. Several health care professionals (for example, psychologists, social workers, occupational therapists, and dietitians) may be involved in the
treatment plan. The psychiatrist should communicate regularly with the patient and the treatment team, and the treat ment objectives should be frequently reevaluated. As the
patient moves toward greater autonomy and off-ward privileges, a challenge for the psychiatrist is to balance the risk of
autonomy against suicidality (as discussed previously). Clinicians should ensure thorough and regular documentation
describing how risk was evaluated and managed.
The goal of an inpatient admission is to restore function to the
point where outpatient treatment can resume. Hence, discharge planning should begin on admission. Discharge requires coordination of the interdisciplinary team, the patient,
and the community follow-up resources. Active discharge
planning ensures that patients, family members, and everyone involved in care are aware of the follow-up arrangements.
Timely completion of the discharge summary promotes communication with the community follow-up. The psychiatrist
should verify that all abnormal laboratory results are addressed, correspondence answered, and forms completed.
The Canadian Journal of Psychiatry

View management as a continuum of overlapping assessment, treatment, and discharge phases.

Restore personal safety and improve functional capacity to facilitate

the transfer to outpatient care.

Involve the patient and community health care workers in discharge

planning.

Recognize that the immediate postdischarge period is a time of

increased risk for suicide.

9. What are the important medical-legal issues?

Issues of confidentiality should be discussed early in the
course of treatment. Patients should be informed that confidentiality could be broken if they are a danger to themselves
or others, if there is evidence of abuse or neglect toward a
child, or by orders from the courts (5760). The rules regarding confidentiality vary from province to province; therefore,
each psychiatrist needs to become acquainted with the laws of
his or her jurisdiction. If there is doubt regarding an issue of
confidentiality, the physician should seek legal advice and/or
contact the provincial college of physicians.
The risk of committing an act of violence against themselves
or others should be assessed in every patient with depression.
Psychiatrists cannot assume patients will spontaneously
bring up homicidal or suicidal ideas or intentions (61,62).
Guidelines for confidentiality, regulations by provincial colleges of physicians, and legal precedents (for example, Wenden v Trikha in Canada and Tarasoff in the US) uniformly
maintain that a psychiatrist has a duty to inform identifiable
third parties at risk and, in emergencies, the police (63).
Psychiatrists have an ethical, and in some provinces legal, obligation to alert the provincial ministry of transportation when
their patient is incapable of safely driving a motor vehicle
(64). Patients with depression may be impaired by their ill ness or by the side effects of medications. Some may use a vehicle as a means to harm themselves or others (65). The
psychiatrist also needs to recognize the implications of treating a licensed pilot, because there are strict rules regarding the
use of psychotropics by those with an aviation licence (66).

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II. Principles of Management

Various liability issues arise in prescribing psychotropic

medications (67). Patients should be warned about potential
side effects that may affect motor functioning (for example,
slowing of coordination and reaction time) or cognitive functioning, so that they can take corrective actions to avoid accidents and physical injury.
Documentation has an important role in clinical practice. Incomplete records and notes are major contributing factors to
the legal difficulties physicians may experience when required to defend a clinical decision; the best legal defence is a
detailed and complete clinical record. When completing insurance forms and legal forms such as involuntary admission
forms, the clinician must ensure that criteria for disability or
impairment are met, that statements are supported in the clinical notes, and that handwriting is legible. Providing clinical
information to such third parties as insurance companies requires a recently signed consent to release information from
the patient (68). A specific consent to release information is
advisable when electronic data transmission is being used. It
is also helpful to discuss with the patient the implications of
releasing such information (for example, what information is
being released and to whom).
CONCLUSIONS
Treating patients with depression is a complex task because
of the wealth of information to be considered in making clinical decisions. Each psychiatrist has a unique background of
knowledge and experience, along with personal preferences
for certain treatments. These general principles for the management of depressive disorders can guide clinicians to provide comprehensive treatment plans.
ACKNOWLEDGEMENTS
The authors thank the following for their contributions: Dr K Roy
MacKenzie, Dr Julio Arboleda-Flrez, Dr Yvon Lapierre, Dr Paul
Links, Dr Arun V Ravindran, Dr Pierre Vincent, and Dr Isaac Sakinofsky contributed to early drafts of this paper; Dr Garth Kroeker
provided external peer review.

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