Background
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No or insufficient level of evidence addressing the question.
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Possibility to decline the topic in easily identifiable clinical situations.
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Need to identify and select the strategies deemed appropriate by an independent panel from amongst several alternative options.
Methods
Recommendations
Comorbid anxiety disorders
During the first episode of MDD with comorbid anxiety disorder, it is recommended in first intention
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The concurrent treatment of both disorders
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The disease management by the same therapist as much as possible, which includes systematically a cognitive behavioural therapy along with a closer follow-up.
Comorbidity | First intention | Second intention | Contra-indications |
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Obsessive-compulsive disorders | - SSRI - SNRI - Psychotherapy in combination | - Imipraminic - α2 Antagonist - Association of two ATDs from different pharmacological class - Potentiation with AAP | - Tianeptine - Irreversible non selective MAOI - First-generation antipsychotic - Anticonvulsant - Bupropion |
Panic disorders | - Imipraminic - α2 Antagonist | - Association of ATDs - Anticonvulsant - First-generation antipsychotic - AAP | |
Social anxiety | |||
Generalised anxiety disorder | |||
Post-traumatic stress disorder |
Comorbid substance use disorders
During the first episode of MDD with comorbid substance use disorders, it is recommended in first intention
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The recourse to full time hospitalization or
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The close monitoring in consultation (at least weekly),
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The electrocardiogram before treatment administration,
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The initiation of a substitution treatment in opioid drug dependence
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The close biological monitoring (complete blood count, blood electrolyte, liver and renal functions),
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The treatment of physical withdrawal syndrome,
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The prescription of antidepressant treatment after reassessment of mood, once appropriate care for physical withdrawal syndrome is over.
Comorbidity | First intention | Second intention | Contra-indications |
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Severe substance use disorders (except alcohol and nicotine) | - SSRI - SNRI - α2 antagonist - Concurrent treatment of MDD and addiction - Disease management involving a team specialised in addictology, psychoeducational groups or a psychotherapy focusing on addictive relapse prevention | - Imipraminic - Agomelatine | - Tianeptine - Irreversible non selective MAOI - First-generation antipsychotic - Association of ATD - Anticonvulsant |
Severe comorbid alcohol addiction
| - SSRI - SNRI - α2 antagonist - Structured Psychotherapy | - Disulfiram - Tianeptine - Bupropion - Irreversible non selective MAOI - Treatment of MDD alone | |
Active smoking
| - SSRI - SNRI - α2 antagonist - Structured Psychotherapy - Concurrent treatment of MDD and smoking-cessation | - Imipraminic - Agomelatine | - Irreversible non selective MAOI - Tianeptine |
Personality disorders
During the first episode of MDD with comorbid personality disorder, it is recommended
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The use of SSRI or SNRI in monotherapy or in combination with a psychotherapy in first intention
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The prescription of imipraminic antidepressant or α2 antagonist in second intention
Geriatric depressive disorder
During an episode of MDD in adults over 65 years of age, it is recommended in first intention to perform a physical examination and ordering laboratory investigations to identify any medical problems that could contribute to or mimic depressive symptoms
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A clinical examination
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A Biological check-up (ie Complete blood count, blood electrolyte, liver and renal functions, Thyroid-Stimulating Hormon)
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An Electrocardiogram
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A Mini Mental State Examination
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The Assessment of the severity of patients’ clinical condition with clinician-rated and self-rated scales.
Clinical features | First intention | Second intention | Contra-indications |
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Mild to moderate intensity | - SSRI - α2 antagonist | - SNRI - Agomelatine | - Irreversible MAOI - Bupropion - Association with an ATD from the same pharmacological class - Anticonvulsant - ECT |
Moderate to severe intensity | - SSRI - SNRI - α2 antagonist | - Imipraminic | - Bupropion - Association with an ATD from the same pharmacological class - Anticonvulsant - First generation antipsychotic |
Severe cognitive impairments | - SSRI - SNRI | - α2-antagonist - Agomelatine | |
Severe psychomotor agitation | - SSRI - α2 antagonist | - SNRI - Potentiation with AAP | - Bupropion - Tianeptine - Irreversible MAOI - Association with an ATD from the same pharmacological class |
Severe psychomotor retardation | - SSRI - SNRI | - α2-antagonist - Imipraminic - ECT in association | - Tianeptine - Bupropion - Association with an ATD from the same pharmacological class - First generation antipsychotic |
Severe sleep disorders | - SSRI - α2 antagonist | - SNRI - Agomelatine | - Tianeptine - Irreversible MAOI - Bupropion - Association with an ATD from the same pharmacological class |
Severe anhedonia | - SSRI - SNRI | - α2-antagonist - Imipraminic - Agomelatine | - Association with an ATD from the same pharmacological class - Anticonvulsant - First generation antipsychotic |
Psychotic symptoms | - SNRI - Potentiation with AAP | - SSRI - α2-antagonist - Imipraminic - ECT in association | - Tianeptine - Irreversible MAOI - Bupropion - Association with an ATD from the same pharmacological class |
High suicidal risk | - SSRI - SNRI | - α2-antagonist - Imipraminic - ECT in association Potentiation with AAP | - Tianeptine - Bupropion - Association with an ATD from the same pharmacological class - First generation antipsychotic |