Treatment Chart Instructions - Black Dog Institute

TREATMENT CHART - INSTRUCTIONSPurposeThe purpose of the following Treatment Chart is to provide your doctor or therapist with arecord of all treatment you have undergone to manage your depression to date.InstructionsPrior to your appointment, please complete the Treatment Chart attached to this instructionpage. Please provide as much information about the different types of treatment (includingpsychological interventions such as counselling, or psychotherapy and/or anti-depressantmedications, or electro-convulsive therapy - ‘ECT’):you have had over the years, or are currently undergoing, andhow helpful you think each treatment has been.To assist you in completing your own Treatment Chart, we have included:a ‘Sample Chart’a Treatment Identification List.Sample OnlyTREATMENT CHARTAgeCommencedMedication Dose Duration Effective? Reason for stopping25 Prothiaden 100 mg/day 6 mths Yes Had been well for sometime so stopped taking it32 Zoloft 50 mg/day 8 wks Slightly Had side-effects32 Cipramil 20 mg/day 7 mths Yes Improved, decided not tocontinue34 Prozac 40 mg/day 3 mths No Was totally ineffective37 Efexor-XR 75 mg/day 12 mths Partly Still taking thisAgeCommencedPsychologicalTherapySessionsOver howlongEffective?Why stopped25 Counselling 4 sessions 3 months Partly Did not want to continue34 Cognitivebehaviour therapy(group)6 sessions 6 weeks Yes/mostly Finished the prescribedcourse of group therapyAgeCommencedECTNumber oftreatmentsOver howmanyweeksEffective?Why stopped36 Bilateral ECT 8 4 weeks Partly Memory problemsThis document may be freely downloaded and distributed on condition no change is made to the content. The information in thisdocument is not intended as a substitute for professional medical advice, diagnosis or treatment. Not to be used for commercialpurposes and not to be hosted electronically outside of the Black Dog Institute website. www.blackdoginstitute.org.au

TREATMENT CHARTAgeMedication Dose Duration Effective? Reason for stoppingCommencedAgeCommencedPsychologicalTherapySessionsOver howlongEffective?Why stoppedAgeCommencedECTNumber oftreatmentsOver howmanyweeksEffective?Why stoppedThis document may be freely downloaded and distributed on condition no change is made to the content. The information in thisdocument is not intended as a substitute for professional medical advice, diagnosis or treatment. Not to be used for commercialpurposes and not to be hosted electronically outside of the Black Dog Institute website. www.blackdoginstitute.org.au

TREATMENT LISTThis list may help you to remember any treatments you may have tried for depression. The drug name is followed by different brand names.Antidepressants Mood Stabilisers Sedative-HypnoticsAMITRIPTYLINE / Endep / Tryptanol / Tryptine / Amitrol CARBAMAZEPINE / Tegretol / Teril / Carbium ALPRAZOLAM / Xanax / Kalma / RalozamCITALOPRAM / Cipramil GABAPENTIN / Neurontin ATIVAN / LorazepamCLOMIPRAMINE / Anafranil / Placil LAMOTRIGINE / Lamictal BUSPIRONE / BusparDESIPRAMINE / Pertofran LITHIUM CARBONATE / Lithicarb / Quilonum SR CLOBAZAM / FrisiumDOTHIEPIN / Prothiaden / Dothep SODIUM VALPROATE / Epilim / Valpro CLONAZEPAM / RivotrilDOXEPIN / Sinequan / Deptran TOPIRAMATE / Topamax DIAZEPAM / Valium / Ducene / AntenexFLUOXETINE / Prozac /Zactin /Lovan /Auscap /Erocap /Fluohexal Antipsychotics FLUNITRAZEPAM / Rohypnol / HypnodormFLUVOXAMINE / Luvox / Faverin AMISULPRIDE / Solian NITRAZEPAM / Alodorm / MogadonIMIPRAMINE / Tofranil / Melipramine ARIPIPRAZOLE / Abilify OXAZEPAM / Serepax / Murelax / AlepamMIANSERIN / Tolvon / Lerivon / Lumin CHLORPROMAZINE / Largactil STILNOX / ZolpidemMIRTAZAPINE / Avanza / Remeron CLOPIXOL / Clopixol TEMAZEPAM / Normison / Temtabs / Euhypnos / Temaze / NocturneMOCLOBEMIDE / Aurorix / Arima / Mohexal CLOZAPINE / Clopine / Clozaril ZOPICLONE / ImovaneNEFAZODONE / SerzoneDROPERIDOL / DroleptanNORTRIPTYLINE / Allegron FLUPENTHIXOL / Fluanxol Depot Psychological TherapiesPAROXETINE / Aropax FLUPHENAZINE / Modecate / Anatensol COUNSELLINGPHENELZINE / Nardil HALOPERIDOL / Serenace / Haldol Decanoate COGNITIVE BEHAVIOURAL THERAPYSERTRALINE / Zoloft OLANZAPINE / Zyprexa GROUP THERAPYTRANYLCYPROMINE / Parnate ORAP / Pimozide RELATIONSHIP/COUPLES THERAPYTRIMIPRAMINE / SurmontilVENLAFAXINE / Efexor / Efexor-XRPERICYAZINE / NeulactilPROMAZINE / SparineQUETIAPINE / SeroquelRISPERIDONE / RisperdalTHIORIDIAZINE / Aldazine / MellerilTHIOTHIXENE / NavaneTRIFLUOPERAZINE / StelazineNB. Please include any other specific psychological therapies youmay have had (eg. grief therapy, assertiveness training, gestalttherapy, psychodynamic therapy etc.)This document may be freely downloaded and distributed on condition no change is made to the content. The information in this document is not intended as a substitute for professional medical advice, diagnosis ortreatment. Not to be used for commercial purposes and not to be hosted electronically outside of the Black Dog Institute website. www.blackdoginstitute.org.au