Start
                            |
             Diagnose organic medical causes,
             drug side effects and drug abuse
                            |
                            |
      __________________Diagnosis?________________
     |                      |                     |
Dysthymic dis. &      Major depression          Bipolar   
Depression NOS     psychotic|nonpsychotic       depression 
    |                  |            |            |
    |                More..(#1)     |           More..(#3)
Mood reactive?                 Melancholic?
  Yes      No                   Yes    No
   |       |__Severely depressed?_|    |        
   |           Yes        No           |
   |            |         |            |
   |         More..(#2)   |            |
   |                      |            |
   |______Adequate trial _|____________|
    ____of SSRI/bupropion SR?_____
   |            |                 |                      
   No        Yes one        Yes more than one
   |            |                 |
 Give   Urgency for relief?       |                            
SSRI/    Not high    High         |
Bup SR      |         |           |
 (01)     Try a      Adequate trial of a
          second   tricyclic, venlafax, mirtaz, or (TCA + SSRI)?
          SSRI/       No                    Yes
          Bup SR      |                      |
           (02)  Add TCA or replace     Is this an
                 with tricyclic,      Atypical depression? 
                 venlafaxine          Yes           No
                 or mirtazapine        |             |  
                    (03)     Adequate trial of MAOI? |
                            (Bupropion may precede.) |
                             No             Yes      |
                             |               |       |
               Try MAOI (bupropion may       |       |
                    precede) (04)            |       |
                                             This is a 
                                PHARMACOTHERAPY RESISTANT DEPRESSION
                                             More..(#4) 



                                 [Go to source of this branch]
                   #1. Continuing from:
                Major depression, psychotic
                            |
        If severely ill, have you considered ECT?
          No                                  | 
          |                       Milder illness, tried ECT,  
       Try ECT (05)                  or ECT unacceptable?
                                              |
     Adequate trial of tricyclic + antipsychotic?
        Yes                        No
         |                         |
         |       Is trial of this combination acceptable?
         |       Yes          TCA unac-       Prefer to avoid 
         |        |           ceptable         antipsychotic
         |    Try TCA +          |                     |
         | antipsychotic (06)    |                     |
         |                  Adequate trial of          |
    Adequate trial         SSRI + antipsychotic?       |
  with lithium added?         No            Yes        |
     No         Yes           |              |         |
     |           |        Try SSRI +      Trial of     |
Add lithium;  Trial of  antipsychotic;   added Li+?    |
Reconsider     methyl-   (? AP alone)    No     Yes    |
ECT (07)     phenidate?     (25)         |       |     |
            No       Yes       Reconsider ECT   ECT    |
            |         |        or add Li+ (10)  (11)   |
      Add methyl-    ECT;                          Trial of 
      phenidate   (? clozapine)             antidepressant alone?
        (08)        (09)                   Yes             No
                                            |              |
                                         Add Li+   Try 3° amine
                                          (12)     TCA; Certain SSRI's:
                                                   worthy of more study 
                                                         (13)                                                                                                                           
 

                            [Go to source of this branch]
                  #2. Continuing from:
                 Severely depressed: Yes
                            |
             Is there significant ischemia?
               Yes                 No
                |                  |
             Choose       Significant dementia?
         Pharmaco-   ECT    Yes             No
         therapy    (26)     |              |
           |                 |     Trial of tricyclic?
     Trial of SSRI or bupropion?     Yes        No
      No              Yes             |         |
      |                |              |    Try tricyclic,
Try SSRI or   Reconsider ECT?         |   venlafax/mirtaz
bupropion    accepts   rejects        |       (15)
 (14)          |          |           |
           ECT (27)       |           |
                          |     Trial of SSRI added?
     Trial of venlafax/mirtaz,       Yes       No      
     lithium augmentation etc.?       |        |  
           No            Yes          |  Try adding SSRI (16)
           |              |           |         
Try venlafax/mirtaz   This is a PHARMACOTHERAPY RESISTANT 
 or lithium augmen-           DEPRESSION 
 tation etc. (17)                  More..(#4)  
                


                                 [Go to source of this branch]
                    #3. Continuing from:
                     Bipolar depression
                             |
                     Urgent indication for ECT present?
                       No          Yes
                        |           |
                        |       ECT recommended. If refused or unsuccessful, 
                        |        go on to the next question. (46)
                        |           |
                 Is the patient psychotic?
                       No          Yes
                        |           |
                        |       Include antipsychotic in regimen below.
                        |           |
   _____________________Bipolar type?_______________________
   Bipolar II      Bipolar I          Mixed or rapid cycling
      |                |                       |
   More..(#5)          |                   More..(#6)
     __________Current medications?________________________
     Lithium          VPA, CBZ, etc.      No mood stabilizers
   (+/- others)           |                     |
       |               Optimize                 |
Li level >0.8?         levels            Depression severity?
|         |            to prevent    Moderate/Severe     Mild
No      Yes (or        cycling            |                |
|     intolerable)       |          Trial of SSRI       Try Li
Raise     |              |          or bupropion +       or... 
level   Tried adding SSRI or        lithium or VPA     (20[P])
 to         bupropion?               (19[P])
0.8-1.2    No      Yes                    
(18[P])    |        |                       
     Add SSRI   Second trial of          
  or bupropion   SSRI/bupropion?                                 
     (21[P])     No        Yes  
                  |         |                        
          Add SSRI or   Trial of venlafaxine?   
     bupropion (22[P])   |               |
                         No             Yes        
                         |               |
               Try venlafaxine,   Consider comorbid conditions,
              or others (23[P])      consider MAOI or ECT
                                Refractory Bipolar Depression (24[P])

                           [Go to source of this branch]
                 #4. Continuing from:
       This is a PHARMACOTHERAPY RESISTANT DEPRESSION
                          |
                   Melancholic type?
            non-melancholic        melancholic
            (mood reactive)    (mood non-reactive)
                    |                   |
                    |          Comment on melancholia
           Personality disorder?        |
                    | | | | |           |
       Comment <-- Avoidant             |
       | Comment <--Borderline          |
       | | Comment <--Narcissistic      |
       | | | Comment <--Dependent       |
       | | | | Comment <--None of above |
       | | | | |                        |
 Comorbid condition? <------------------|
 |  |  |  |  |  |  |
Panic disorder
 | OCD
 |  | ADHD
 |  |  | PTSD
 |  |  |  | Chronic pain
 |  |  |  |  | Moderate anergic depression with medical illness
 |  |  |  |  |  | None (or, you followed up on the comorbidities)
 |  |  |  |  |  |  |
 |  |  |  |  |  |  Try additional single treatments: e.g.
 |  |  |  |  |  A  SSRI's (maybe high dose), TCA's,
 |  |  |  |  |  n     clomipramine (if no ischemia), MAOI's
 |  |  |  |  |  e  Consider ECT.Try enhancement strategies: 
 |  |  |  |  |  r  lithium, bupropion, thyroid, stimulants, 
 |  |  |  |  P  g  pindolol, buspirone, MAOI with lithium
 |  |  |  |  A  i  or stimulants. (28)
 |  |  |  P  I  c
 P  O  A  T  N  Try stimulants (29)
 A  C  D  S  |
 N  D  H  D  Try carbamazepine, amitriptyline, tramadol
 I  |  D  |     clomipramine, venlafaxine (30)
 C  |  |  Consider trazodone for sleep. Substance abuse?
 |  |  |    Yes--> Add valproate or carbamazepine; ?gabapentin (32)
 |  |  |    No---> Benzodiazepines; then valproate, carbamazepine, 
 |  |  |             antipsychotics for psychosis NOS, MAOI's (31)
 |  |  |
 P  O  Substance abuse?
 A  C    Yes--> Consider bupropion; venlafaxine (if not cocaine user) (33)
 N  D    No-->  Consider stimulants, bupropion, venlafaxine (34)
 I  |
 C  Consider: high dose SSRI then clomipramine +/- SSRI;
 |   then other enhancers (Li+, buspirone, MAOI): if psychotic
 |   features or tics, consider antipsychotics (35)
 |
 Try: Benzodiazepines, Low dose SSRI, Valproate, MAOI (36)



                                 [Go to source of this branch]
                   #5. Continuing from:
                Bipolar II (not rapid-cycling)
                             |
       Candidate for monotherapy with an antidepressant?
                 Yes                        No
                  |                         |
        Tried SSRI or bupropion?   Treat the same as bipolar I
        No                   Yes       More..(#3)   
        |                     |      
 Try SSRI/bupropion      Another trial of SSRI/bupropion?
     (37[P])              No                     Yes        
                          |                       |       
                     Do another          Tried venlafaxine?                                              
                    SSRI/bupropion       |               |
                    trial (38[P])        No             Yes 
                                         |               |
                             Try venlafaxine    comorbid conditions
                            or others (39[P])   Consider an MAOI or ECT
                                             Refractory Bipolar Depression (40[P])                                                  
                                      


                              [Go to source of this branch]
                    #6. Continuing from:
           Bipolar I or II: Mixed or rapid cycling
                            |
      Predisposing factors considered and addressed?
              Yes                         No
               |                          |
     Current medications?          Address factors where
     No mood        One or more       possible (41[P])
    stabilizer     mood stabilizers
        |               |
     Try VPA    Tried adding second mood stabilizer?
     (42[P])         |                       |
                     No                     Yes
                     |                       |
           Try adding second           Bipolar subtype?
        mood stabilizer (43[P])        |              |   
                                   Bipolar I        Bipolar II 
                                       |              |                  
               Consider third mood stabilizer.    Consider third mood stabilizer,
               If antidepressant chosen, start    ECT, or newer antipsychotics. If 
               bupropion or SSRI. Use low dose,   antidepressant chosen, start 
               go slow strategy (44[P])           bupropion or SSRI. Use low dose, 
                                                  go slow strategy (45[P])