eMJA: Hickie, An approach to managing depression in general practice

eMJA The Medical Journal of Australia

Clinical Practice

An approach to managing depression in general practice

Ian B Hickie

MJA 2000; 173: 106-110

Long term management of patients with depression: an essential skill for all general practitioners

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Abstract - Early detection - Diagnostic pragmatism - Risk assessment - Engaging and empowering - Choosing an antidepressant - Beyond drug therapy - Conclusion - Authors' details
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Abstract

Detection of depression in primary care can be enhanced by use of self-report assessment forms.
With the new classes of antidepressants, there is the opportunity to choose specific drug classes for different types of depressive disorders.
Depression is frequently a relapsing illness. Treatment goals should include long term reduction of vulnerability factors.
An active therapeutic partnership can be facilitated by providing accurate detailed information early in the course of the illness.
Behavioural therapies, which focus on modification of the sleep-wake cycle, activity planning and reduction of substance abuse, are essential.
Structured problem solving is the most accessible form of cognitive intervention that general practitioners can readily provide.
More complex cognitive therapies are usually provided by mental health professionals or general practitioners with extensive training.

Although major depression is common in primary care, general practitioners (GPs) may still find it difficult to detect and treat depression unless they have a high index of suspicion and additional mental health training.^1-3 A range of patient, doctor and practice organisation factors contribute to this difficulty.^1-4 Patient factors include comorbid medical disorders, presentation of somatic rather than psychological symptoms, poor understanding of mental health and fear of stigma. Examples of practitioner factors are inadequate training and reluctance to provide psychological treatments, whereas practice organisation factors include too little time, too little remuneration, too little mental health specialist support, lack of use of screening tools, and lack of access to independent educational materials. However, improvement in the quality of mental health care provided by GPs is now firmly on the national agenda.⁴

High quality mental health care consists not only of informed prescribing, but also of early detection, provision of sound information, use of effective non-pharmacological techniques and reduction in factors which will lead to long term vulnerability to recurrent depression. A range of initiatives are under way nationally to improve mental health practice in primary care. In this article, elements derived from SPHERE: A National Depression Project are described to highlight one coordinated approach to the educational, training and practice support infrastructure needed to make such initiatives sustainable.⁵

Early detection in primary care

GPs are ideally placed to detect depression early in its course. While patients frequently present with other urgent medical problems or unexplained physical symptoms,^2,6 primary care contacts are ideal for mental health screening. Although much mental health training focuses on improving interview and assessment skills, simple screening instruments are time-efficient and engage patients actively in the therapeutic process. As with other screening procedures, such tests are not diagnostic. Instead, they highlight those patients who require specific assessment by the practitioner. Patients usually welcome the opportunity to reveal their difficulties in this way. Good examples of such instruments include the 12-item General Health Questionnaire (GHQ),⁷ the Prime-MD,⁸ and the 34-item Somatic and Psychological HEalth REport (SPHERE).⁵ SPHERE can be used to produce an output that compares the severity of the patient's physical and mental symptoms with a national practice sample. Currently, the SPHERE Project promotes a simple screening device (Box 1), which emphasises that depression is a syndrome with major effects on thoughts, feelings, behaviours and bodily function.

Diagnostic pragmatism

Formal psychiatric classification systems have become extremely complex and lack validity in primary care.³ However, for GPs to make use of the available evidence on treatment efficacy, certain grades of depression need to be recognised. British and European psychiatry has emphasised the importance of identifying "endogenous" or "melancholic" disorders, as they respond preferentially to antidepressant drugs. The depressed phase of bipolar disorder (manic depressive illness) also fits this category. Recent Australian research has re-emphasised this concept,⁹ highlighting the need to recognise observed (not patient-reported) psychomotor slowing, or agitation, as hallmarks of the disorder. Melancholia is relatively rare in primary care (as distinct from specialist and hospital-based practice).

In primary care, non-melancholic depressive disorders (either primary, concurrent with anxiety or secondary to medical illness) are common and disabling.^1,2,10,11 Key risk factors include premorbid anxiety, family history of anxiety, depression and substance abuse, medical ill-health, dysfunctional intimate relationships, and social adversity. Increasing sophistication of genetic,¹² biochemical and psychosocial research has led to a new conceptualisation of these disorders, with greater emphasis on the interaction between long term (genetic and past experiential) vulnerabilities and current life stressors. That is, depression rarely occurs "out of the blue", and patients who have had major episodes are at high risk of relapse.¹³ Further, in this model, patients with non-melancholic disorders have their own individual biology (genetically determined arousability or nervousness) that may be treated pharmacologically or non-pharmacologically. Diagnostically, it is important to recognise not only the overt depressive disorder but also whether it is accompanied by a specific anxiety disorder (eg, panic attacks or agoraphobia) that requires additional attention. The recognition of premorbid anxiety, substance abuse and/or significant personality dysfunction completes this diagnostic phase.

Risk assessment

One of the most important tasks in primary care is the assessment of risk of various forms of self-harm. Prevention of suicide should not be seen as the primary goal; nevertheless, research has highlighted the high risks of self-harm in both younger and older men, with the latter frequently contacting family doctors before making serious suicide attempts.¹⁴ Other risk factors, such as social isolation, substance abuse and access to lethal means, need to be noted and appropriate risk-reduction strategies implemented (eg, involvement of family, frequent appointments, emergency contact procedures, reduction of alcohol, removal of lethal means). GPs can underrate the degree of both short- and longer-term risk,¹⁵ and may need to engage others (eg, family, other primary care practitioners, or mental health specialists) more actively in collaborative long term risk reduction. A necessary emphasis is the assessment of a range of risk-taking strategies (eg, deliberately driving fast or recklessly) and forms of self-harm other than overt suicide attempts (eg, prolonged substance abuse, neglect of other medical problems).

Engaging and empowering the patient

The community has little specific knowledge about depression, and patients hold generally negative views about antidepressant drug therapy.¹⁶ The key to overcoming these negative stereotypes is the provision of independent and sophisticated information. Most patients wish to make active choices about treatment and, increasingly, to receive alternative opinions, but few practitioners have the materials they need to facilitate such discussions. Furthermore, some are reluctant to provide detailed information that may apparently contradict their therapeutic choices. Provision of accurate information early in the course of illness facilitates active engagement and helps create the framework for long term treatment adherence.¹⁷ While these concepts are now routine for disorders such as diabetes and asthma, they are yet to become routine even among mental health specialists who treat severe and/or relapsing depression.

Choosing an antidepressant

The new classes of antidepressants differ substantially in their benefits and side-effects. Rather than prescribing the same antidepressant (or the same class) to every patient with depression, there is the chance to choose specific classes for different types of depressive disorders. Pharmacological therapy should be accompanied by appropriate means for recording benefits and side-effects and placing drug therapy within an overall treatment framework. One also needs a "road-map" for initiating rational prescribing (Box 2).

Currently, there is a general paucity of comparative evidence to influence choices of antidepressant compounds (both within and across classes). Internationally, this has meant a reliance on panels of experts rather than systematic reviews of published studies. In the course of designing the SPHERE Project, we relied strongly on the clinical opinion of experts and a survey of practitioners.^18,19 Subsequent studies^20,21 and professional group recommendations²² are largely consistent with these views. Consequently, we still recommend some specific starting points for antidepressant therapy. These include:

Selective serotonin reuptake inhibitors (SSRIs) are particularly helpful for those with moderately depressed mood, premorbid anxiety and/or panic disorder, agoraphobia and/or obsessive-compulsive disorder.^23,24 They are also "first-line" agents for depression in the context of other medical illnesses, adolescents, and older patients.^19,22 Generally, these drugs are very similar and good reasons for choosing one over another are limited.
When selecting an SSRI, factors to consider are drug interactions (cytochrome P-450 enzyme systems), severity of withdrawal syndromes, and tendency to cause initial agitation.
Patients with principal complaints of fatigue and/or sleep disturbance, without severe mood disturbance, may require different strategies. Fatigue without obvious mood disturbance responds poorly to SSRIs,²⁵ and SSRIs may be associated with worsening sleep patterns in the first few weeks of therapy.²⁶ Some of these patients may benefit from the use of other antidepressant classes. Preliminary evidence suggests the usefulness of moclobemide in patients with fatigue,²⁷ and nefazodone in patients with fatigue and sleep disturbance.²⁸
Patients who do not respond to a course of SSRIs may instead respond to serotonin and noradrenaline reuptake inhibitors (SNRIs).²⁰ Whether to use SNRIs as first-line agents in primary care is debatable, but psychiatrists do not generally recommend them in this setting¹⁹ because of their side-effects and more complex dosing schedule. They are strongly favoured for use in specialist practice where patients have generally failed one or more courses of the first-line agents or have more severe illnesses.
Patients with melancholia, psychotic depression, treatment-resistant depression and/or other very severe mood disorders may do less well with SSRIs and may benefit from commencing therapy with SNRIs²⁰ or tricyclic antidepressants (TCAs).²⁹
Some particular patient groups (eg, those with chronic pain) still respond preferentially to TCAs.¹⁹

Beyond drug therapy

A great deal of educational effort has been invested (largely by the pharmaceutical industry) in increasing doctor recognition of major depression and provision of safer pharmacological therapy. Unfortunate consequences of this drive may be the perception that these agents are more efficacious than the older agents or that non-pharmacological strategies are no longer relevant.³⁰ Although initial drug therapy can assist patients to get "out of the hole", ongoing maintenance therapy (Box 3) is also critical.

Maintenance therapy needs to be thought of in terms of How long should this patient stay on the drug? and What other non-pharmacological strategies are necessary for this patient?.

One of the clear (and somewhat unexpected) benefits of the SSRIs is their capacity to reduce ongoing "trait" anxiety in those who have been life-long worriers.²³ That is, they appear to modify a personality style that is otherwise at high risk of recurrence of depression. In general, patients should continue effective drug therapy for at least 6 to 12 months after they recover from a major depressive episode. If patients have had several previous depressive episodes, and have responded to drug therapy, then they should consider longer periods (2 to 5 years) of prophylactic antidepressant therapy.²²

The effective non-pharmacological therapies are generally lumped together as "cognitive-behavioural" approaches. This describes a range of potential interventions that commence with essential behavioural elements (eg, education, treatment adherence monitoring, sleep-wake cycle and activity planning, modification of substance use; see Box 4)³¹ and then move to more cognitive approaches (eg, structured problem solving, formal cognitive therapy). While debate continues as to the extent of benefit from these approaches,³² it is generally accepted that they form the basis of most non-pharmacological interventions.^22,33 There is an ongoing issue of practitioner competency, as such treatments are not necessarily effective if provided by clinicians with limited training.³⁴

For all patients, keeping a daily diary is an essential part of the behavioural approach. A very good analogy for patients with depression is that of diabetes. Whatever drug therapy may be required, major lifestyle modifications are also needed. The more effective the non-drug therapy, then the greater the chance that the patients will be able to withdraw drug therapy. Many doctors provide lifestyle advice, but fail to encapsulate it within other critical features of the behavioural approach, such as explaining the rationale, self-monitoring, reviewing the effects of modified behaviour, and identifying obstacles to implementation. Behavioural management of anxiety (eg, general stress, panic attacks, avoidant behaviour, social anxiety) needs to be considered in those with high premorbid anxiety or ongoing anxiety phenomena. This may include general stress management (including physical exercise), slow-breathing techniques, progressive muscle relaxation, and staged confrontation of feared situations (exposure therapy). In general, patients with significant anxiety disorders do best when they receive cognitive as well as behavioural approaches.

Structured problem solving

Many untrained professionals confuse effective psychological interventions (eg, structured problem solving, interpersonal therapy, cognitive therapy) with non-specific support and advice. Although the latter may help reduce the risk of self-harm, they do little to resolve major depression. The most accessible form of psychological intervention for primary care practitioners is structured problem solving.³⁵ This creates a framework for the patient to re-engage with practical approaches to perceived problems and learn new cognitive skills (Box 5). The key factor is not whether the patient's preferred solution is ultimately successful (which tends to be the doctor's main preoccupation), but whether the patient learns a more general approach to coping with ongoing life stressors. By focusing initially on a style of behavioural analysis that describes specific rather than general problems, and then ranks them in terms of likely difficulty, the patient is forced to move from a position of general hopelessness (eg, "There's nothing I can do", "Everything fails in the end") to more specific problems (eg, "I don't have a job"). Identifying specific problems allows the generation of option lists (eg, "Ask family", "Register with Centrelink", "Change industries"). Once a reasonable option list has been generated, the patient then evaluates the potential interventions. That is, the patient is being forced to engage in the style of rational thinking that people without depression take for granted. By contrast, patients with depression tend to think in global terms, generate few solutions, fail to evaluate their actions, and avoid implementation of realistic options.

This approach is well suited to general practice as it can be learnt quickly, requires little ongoing supervision, and can be broken down into manageable time frames (eg, three to six sessions of 15 to 30 minutes each). As with other cognitive approaches, it engages the patient as an active partner and formally prohibits practitioners from simply offering their own behavioural analyses and/or preferred solutions. It may also prove to be a useful means for recruiting additional input from other key people (eg, spouse or parent), as they may be encouraged to generate additional options or assist with implementation. As many depressed patients find themselves in dysfunctional intimate relationships,³⁶ this change of focus may also assist to re-engage those who have found interactions with the depressed person non-rewarding or aversive.

Cognitive and interpersonal therapies

These more formal psychological therapies are suited to patients with repeated episodes of depression, chronic depression, or clear evidence of repeating patterns of self-defeating thoughts, avoidant behaviours, or dysfunctional intimate relationships.^33,37 These treatments can be difficult to provide in primary care, as they require considerable therapist training, ongoing supervision and monitoring of clinical skills, and modification of the practice environment (typically 12 to 16 sessions of 45 minutes' duration). However, GPs have indicated a willingness to learn key aspects of these skills and implement them in their practice.³⁸ Widespread provision of these treatments will require more radical training and financing. These may be in the form of more "shared" and better-structured care with secondary mental health specialists systems,³⁹ or through the development of a large group of GPs with these specialised skills.

Conclusion

Most GPs can now provide reasonable antidepressant therapy for patients they identify as having depression. Improved quality of practice depends on greater identification (particularly in those with concurrent medical illness), better quality of initial psychoeducation and behavioural management, and initiation of psychological strategies designed to improve treatment adherence and reduce long term vulnerability.

Acknowledgements: The assistance of Tracey Davenport and Joanne Gander with the preparation of this manuscript was greatly appreciated.

Disclosure statement: SPHERE: A National Depression Project was supported in 1998 and 1999 by Bristol-Myers Squibb Pharmaceuticals, manufacturers of Serzone (nefazodone). Evaluation of the SPHERE Project is currently supported by the New South Wales Health and Mental Health Branch of the Commonwealth Department of Health and Aged Care. Australian Divisions of General Practice provide financial support for SPHERE training programs in local districts. A trial of Aurorix (moclobemide) in patients with chronic fatigue was supported by Roche Pharmaceuticals. Pfizer, manufacturers of Zoloft (sertraline), plan to support a SPHERE education module (Depression in the Medically Ill) in 2000. Representatives of the SPHERE Project have provided educational sessions for employees of Wyeth Pharmaceuticals, manufacturers of Efexor (venlafaxine).

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Authors' details

School of Psychiatry, University of New South Wales, Sydney, NSW.
Ian B Hickie, MD, FRANZCP, Professor of Community Psychiatry.

Reprints: Professor I B Hickie, Academic Department of Psychiatry, 7 Chapel Street, Kogarah, NSW 2217.
i.hickieATunsw.edu.au

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