In general, individuals with major depressive disorder should be followed closely in treatment, all the more so when they are in the midst of a major depressive episode. Moderate to severe episodes of major depression require more frequent follow-up than mild episodes. Additionally, if an individual decides to start a course of anti-depressant medication, he should be monitored closely for his response to the medication and side-effects.

Because any given dose of a conventional anti-depressant medication can take 4-6 weeks - or even longer, sometimes - to show its full therapeutic effect, medication dosage adjustments should generally not be made on a more frequent basis once a potentially therapeutic dose has been reached. At the same time, side-effects often emerge early in the course of treatment. Sometimes, it is necessary to make a dosage adjustment (e.g. lower dosage) or a switch to a different anti-depressant medication, especially if side-effects are intolerable and not ones that are expected to subside gradually over time.

Individuals in psychotherapy for a major depressive episode are normally seen on a once-weekly basis, sometimes more frequently if the depressive episode is felt to be more severe.

If an individual is on anti-depressant medication and receiving psychotherapy from a therapist who is not the psychiatrist, the therapist and psychiatrist must collaborate to keep each other apprised of the individual's clinical status. Collaboration is especially important when:

1. suicidal thoughts are present
2. psychotic symptoms are present
3. the clinical situation is worsening
4. medications are producing significant side-effects
5. changes in medication are being made

For severe episodes of major depression, acute psychiatric hospitalization is sometimes required. Indications for hospitalization include:

1. Suicidal thoughts, impulses/urges, planning
2. Psychotic features (e.g. paranoid thinking, delusions, auditory hallucinations)
3. Severe functional impairment such that the individual is not able to take care of his basic needs (e.g. eating, attention to hygiene, etc.)

In these instances, vigilance over the individual's safety is paramount and is often best achieved in a hospital setting where clinical staff are available to assess the individual on a continuous basis.

Apart from ensuring the individual's safety, the first goal of treatment of major depressive disorder is to help the individual achieve full remission of symptoms. During this phase of treatment, the individual would be seen by a mental health specialist on a weekly basis, optimally. If he is on anti-depressant medication, he should be seen by a psychiatrist for medication monitoring every 4-6 weeks at a minimum. Children, adolescents and young adults less than 24 years of age, should be monitored more closely - weekly, ideally - because suicidal thinking and gestures can increase in a subset of these individuals when they are initiated on anti-depressant medications.

Once an individual has achieved full remission from a major depressive episode, it is often possible to meet every 3-6 months for maintenance anti-depressant monitoring, especially if the individual is receiving psychotherapy elsewhere and, hence, being clinically monitored.

In my practice, I advise individuals to call me with any worsening of symptoms, troubling side-effects or adverse reaction - and not to wait until the next scheduled appointment.

If an individual who consults with me for major depressive disorder decides upon a course of anti-depressant medication after the initial consultation, I will usually prescribe the anti-depressant medication at half the recommended starting dose (e.g. 10 milligrams of citalopram per day, or 5 milligrams of escitalopram per day). I ask the individual to stay on this dose for 1-2 weeks and then, if tolerated, to double the dose. In my practice, I normally recommend following up 4-6 weeks after the initiation of medication, so that I can determine whether the medication is working and monitor side-effects. During this time, I advise individuals to begin a course of psychotherapy, if they are not already in psychotherapy.