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4 Managing depression in a community setting
Philip B Mitchell There are a range of effective treatments for depression that general practitioners can consider |
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Synopsis - Introduction - The nature of depression in general practice - Are treatments for depression effective in the community setting? - Antidepressant medications - Psychological treatments - Recommendations for treatment - Acute management of depression - Continuation of therapy - Maintenance therapy - When to refer - Antidepressants - Psychological treatments - Conclusion - References - Authors' details - Box 1: DSM-IV criteria for major depression - Box 2: Antidepressants marketed in Australia since 1990 - dosages and adverse effects - Box 3: New antidepressants - important interactions - Box 4: Psychological therapies - Case history 1: Depression presenting as anxiety and insomnia - Case history 2: A professional woman with depression - Short course - Contents list | ||
Synopsis | |||
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Introduction | |||
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At least 15% of the population will suffer from significant
depression at some stage of life, and at any one time about 3%-5% will
have significant symptoms. In general practice, 5% of patients have
major depression and another 5% have a less severe form of this
illness. The depression seen in general practice often coexists with
physical disorder, or may present with physical rather than
psychological complaints.
The disability caused by depression has been underestimated by the medical profession; it has a pervasive effect on physical function, bodily pain, general health, family, work and social relationships, as well as mental health. | |||
The nature of depression in general practice | |||
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Case history 1: |
Depressed patients experience more impairment in quality of life
than patients with common medical disorders.1 They are also higher
consumers of general health care.2 This stems from greater use
of general medical services rather than higher mental health
treatment costs (US$2390 per year as against US$1397 for patients
with common medical disorders).3
General practice patients with depression usually have shorter episodes of depression and meet fewer diagnostic criteria for major depression than those seen in psychiatric clinics.4 Severity is the best predictor of the persistence of depressive symptoms (the more severe the depression, the more likely it is to persist).5,6 Tricyclic antidepressants (TCAs) are the most commonly prescribed antidepressant in general practice, and are usually prescribed at too low a dose:7 80%-90% of prescriptions are less than 125-150 mg daily,8 below recommended guidelines for management of depression in general practice.9 In one study, 52% of the general practitioners used lower than recommended daily treatment doses (as against 17% of psychiatrists) and 40% of the general practitioners as against 7% of psychiatrists prescribed for less than the recommended minimum continuation period.10 | ||
Are treatments for depression effective in the community setting? | |||
| Most studies have been undertaken in psychiatric outpatient practice, with findings being extrapolated to general practice. | |||
| Antidepressant medications |
There is no doubt about the effectiveness of antidepressants in
outpatient psychiatric practice. A comprehensive meta-analysis of
both inpatient and outpatient controlled trials has demonstrated
response rates of 50% to 55%, compared with a 30% response rate to
placebo treatment.11
A trial of amitriptyline12 in general practice found it superior to placebo in patients with major depression, but not in those with minor levels of depression. This study was important in demonstrating that TCAs are of benefit in relatively mild levels of depression, but not in the mildest range. Patients with Hamilton Depression Rating Scale scores of 12 or less were just as likely to respond to the placebo treatment. (The clinician-rated Hamilton scale13 is a widely accepted index of the severity of depression. Scores of 17 or more indicate a significant degree of depression; 7-12 indicates mild depression; and less than 7 is within the normal population range.) | ||
| Psychological treatments | The major study of psychological treatments in depression in general practice is that of Elkin et al., who compared imipramine plus good clinical care with cognitive therapy, interpersonal therapy and good clinical care plus placebo.14 In patients with Hamilton scores of less than 20 (moderately severe depression) there were no differences between any of these treatments, whereas in patients with more severe scores interpersonal therapy was more effective than placebo, although cognitive therapy was not. However, other studies have shown cognitive therapy to be more effective than placebo and of similar efficacy to antidepressants in outpatient depression.15,16 More recently, Mynors-Wallis et al. found that problem solving was as effective as amitriptyline, and more effective than placebo.17 | ||
Recommendations for treatment | |||
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Case history 2: A professional woman with depression | The outcome of a consensus conference of members of the Royal College of General Practitioners and the Royal College of Psychiatrists was published in 1992,8 and a year later the Agency for Health Care Policy and Research (AHCPR) of the US Department of Health and Human Services published the Clinical practice guideline on depression in primary care.11 Both guidelines are now regarded as important benchmarks, although there has been some criticism, particularly with regard to their strong emphasis on antidepressant drugs and correspondingly less stress on the role of psychological treatments, particularly for the mildly depressed.18,19 The major Australian guidelines are in the Psychotropic drug guidelines.20 Clinical practice guidelines for managing depression in young people have recently been published by the National Health and Medical Research Council.21,22 | ||
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Acute management of depression
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Which forms of depression are likely to respond to
treatment? The diagnosis of major depression (Box 1) -- with or without melancholic features -- indicates a strong likelihood of response to antidepressants or psychological treatment. In less severe forms of depression, either long-lasting (dysthymic disorder) or more acute (adjustment disorder with depressed mood), response to treatment is less predictable. None the less, some patients with dysthymic disorder and adjustment disorder do respond to antidepressant therapies. Most patients with major depression in general practice do not have melancholic or endogenous features (i.e., pervasive anhedonia, psychomotor retardation or agitation, or reduced emotional reactivity). Patients with bipolar disorder (manic-depressive illness) must be identified by questioning about possible past episodes of hypomania or mania, as such patients will require a mood stabiliser (e.g., lithium, carbamazepine or sodium valproate) in conjunction with the chosen antidepressant therapy. Similarly, patients with psychotic depression (those with delusions and/or hallucinations) must be identified, as they will require treatment with electroconvulsive therapy (ECT) or a combination of antidepressants and antipsychotics. Many depressed patients seen in general practice also have a physical disorder, and the depression is often caused by their disability, discomfort or distress. This does not preclude the effectiveness of medications or psychological treatments. Rarely, depression may be due directly to the physical condition (for example, with some endocrinopathies or cerebrovascular disease) or the drugs used to treat the disorder (e.g., corticosteroids or treatments for Parkinson's disease). When should antidepressant medications be used? Factors that may suggest the use of antidepressants include incomplete response to psychotherapy alone, a patient request for antidepressants, chronic symptoms (two years or more), previous episodes of depression, a family history of depression, and previous response to antidepressants.11 Combined antidepressant medication and psychological
treatments When to use psychological treatments alone What is an adequate course of treatment? Unfortunately, there are no studies to indicate how long a course of psychological treatment should be continued before such treatment is changed. | ||
| Continuation of therapy | Patients who respond to acute treatment should continue therapy with the same dose of antidepressant for four to nine months to prevent a relapse of the original episode.25 | ||
| Maintenance therapy | Studies have confirmed the value of ongoing medications in preventing recurrences of depression.26 Maintenance therapy should be considered for those who have had three previous episodes of depression, those with two previous episodes if such episodes were recent and severe, and those with a family history of bipolar disorder or recurrent depression.11 For such patients, treatment should be continued for at least two to five years and, for some, indefinitely. | ||
| When to refer | Referral to a psychiatrist should be considered when the patient has bipolar disorder, psychotic depression or active suicidal thoughts; when there is no response to one or two trials of treatment; or when there may be a need for ECT (ECT is effective for patients with psychotic depression or melancholic depression not responding to antidepressants). For patients requiring specialised psychological treatments, referral to either a psychiatrist or clinical psychologist may be necessary, the choice depending on factors such as individual therapist skill and the cost of therapy. | ||
Antidepressants | |||
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Box 2:
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TCAs are still the most commonly prescribed antidepressants in many
countries, including Australia. Although there has been concern
that the newer antidepressants may be less effective than TCAs in
severe or melancholic depression,27 the vast majority of
depressed patients seen in the general practice setting have mild to
moderate depression, for which the new antidepressants are as
effective as the old. As there is consistent evidence of
underprescription of TCAs and as the new medications are safer in
overdose, the following order of antidepressant use in general
practice is recommended: First line: Selective serotonin reuptake inhibitors (SSRIs), venlafaxine, nefazodone, moclobemide or mianserin. Second line: TCAs (desipramine or nortriptyline are preferred as they have fewer anticholinergic effects and are less sedating). Third line: Irreversible monoamine oxidase inhibitors (MAOIs). Details of the dosage, side effects and interactions of the more recently introduced antidepressants are provided in Box 2 and Box 3. What should be done if the patient doesn't respond to a
first-line antidepressant after four to six weeks? What should be done if the patient cannot tolerate the adverse
effects of an antidepressant? Guidelines for changing antidepressants are provided in the Psychotropic drug guidelines.20 The major safety issues are (1) avoiding the serotonergic syndrome by allowing adequate time for drug clearance when switching between the irreversible MAOIs and other antidepressants, and (2) allowing adequate time for drug clearance when switching between SSRIs and other antidepressants, as SSRIs inhibit negative cytochrome P450 enzymes responsible for the metabolism of many of the antidepressants. Withdrawal from antidepressants | ||
Psychological treatments | |||
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A number of psychological treatments have been shown to be effective
for depressed psychiatric outpatients (cognitive therapy and
interpersonal therapy in particular; Box 4), but such treatments do
not easily translate to general practice.
It is useful to discuss psychological treatments in terms of non-specific and specific forms: Non-specific
psychological treatments
Specific psychological treatments
The study of Mynors-Wallis et al. found that problem solving undertaken in either the patient's home or a local health centre was as effective as amitriptyline and more effective than placebo.17 Two of the three therapists in that study were general practitioners. Patients were given the rationale that emotional problems are caused by problems in the circumstances of their life, and that if problems were dealt with effectively symptoms would improve. Problems were then identified, listed, and dealt with one-by-one using problem solving methods. The first session took 60 minutes, with five subsequent sessions of 30 minutes. | ||
Conclusion | |||
| Much of the depression seen in the community can be dealt with adequately by general practitioners, who have a wide range of antidepressant medications and psychological treatments at their disposal to alleviate suffering from this severe and disabling disorder. | |||
References | |||
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Authors' details | |||
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Mood Disorders Unit, Prince Henry and Prince of Wales Hospitals,
Sydney; School of Psychiatry, University of NSW, Sydney.
Philip B Mitchell, MD, FRANZCP, FRCPsych, Associate Professor. Correspondence: Associate Professor P B Mitchell, School of Psychiatry, Prince Henry Hospital, Little Bay, NSW 2036. E-mail: phil.mitchellATunsw.edu.au
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