Difficult-to-treat depression. A guide to management in primary care

It is never too late to confront the black dogIt is two years since I started enjoying the best mornings I have had since childhood, after finally finding a treatment for my underlying depressive condition. I was 12 years old when I first recognised that something was hampering my ability to function properly early in the day. I would wake up feeling very negative, lacking confidence, indecisive, ...

Andrew J Robb MP, DipAgricSci, BEc(Hons)

What can GPs do when a patient with depression does not get better?Depression remains a leading cause of distress and disability worldwide. In the 1997 Australian National Survey of Health and Wellbeing, 7.2% of people surveyed had experienced a mood (affective) disorder in the previous 12 months.1 Those affected reported a mean of 11.7 disability days (when they were “completely unable to carry out or had to cut ...

David J Castle MD, FRANZCP, FRCPsych · Leon Piterman MB BS, MD, FRACGP · Michael Berk PhD, MB BCh, FRANZCP

AbstractObjective: To understand the perspectives of a group of general practitioners regarding management of patients with difficult-to-treat depression (DTTD).Design, setting and participants: A qualitative approach using a focus group and semi-structured telephone interviews conducted in 2011 with 10 GPs from urban and rural Victoria. Five main topics were explored: (1) understanding of DTTD; (2) understanding of other terms used to describe DTTD; (3) ...

Kay M Jones BSW, MT · David J Castle MD, FRANZCP, FRCPsych · Eleanor M Curran MB BS(Hons), BMedSc(Hons), MPM · Leon Piterman MB BS, MD, FRACGP

Summary Depressive symptoms frequently accompany physical illness, but the association between the two is complex. The combination has detrimental implications for the patient’s health outcome, quality of life, medical treatment and health care use. The presence of physical symptoms of the medical illness can lead to challenges in recognising and diagnosing depression. This is best dealt with by placing greater emphasis on the ...

James S Olver MB BS, MD, FRANZCP · Malcolm J Hopwood MB BS, MD, FRANZCP

Summary Depression in patients with cancer can present a challenging clinical problem for both general practitioners and the oncology team. Detecting depression in a patient with cancer, who may be debilitated and in pain, can be difficult. Cancer treatments can complicate antidepressant choices. Community-based psychologists are an important resource for helping manage less complex and less severe psychological problems that can ...

Jeremy W Couper MB BS, MMed, FRANZCP · Annabel C Pollard PhD, MA(Psych), GradDipApplPsych · Dianne A Clifton MB BS, MPM, FRANZCP

Summary Chronic pain and major depression commonly occur together. Major depression in patients with chronic pain is associated with decreased function, poorer treatment response and increased health care costs. The experience and expression of chronic pain vary between individuals, reflecting complex and changing interactions between physical, psychological and social processes. The diagnosis of major depression in patients with chronic pain requires ...

Alex Holmes MB BS, FRANZCP, PhD · Nicholas Christelis FFPMRCA, FANZCA, FFPMANZCA · Carolyn Arnold MB BS, FAFRM, FFPMANZCA

Summary Unhealthy lifestyle behaviour is driving an increase in the burden of chronic non-communicable diseases worldwide. Recent evidence suggests that poor diet and a lack of exercise contribute to the genesis and course of depression. While studies examining dietary improvement as a treatment strategy in depression are lacking, epidemiological evidence clearly points to diet quality being of importance to the risk of ...

Felice N Jacka BA, PgDipSci, PhD · Michael Berk PhD, MB BCh, FRANZCP

Summary Borderline personality disorder (BPD) is a serious mental illness characterised by dysregulation of emotions and impulses, an unstable sense of self, and difficulties in interpersonal relationships, often accompanied by suicidal and self-harming behaviour. Major depressive disorder (MDD) commonly co-occurs with BPD. Patients with BPD often present with depressive symptoms. It can be difficult to distinguish between BPD and MDD, especially when ...

Josephine A Beatson MB BS, FRANZCP · Sathya Rao MD, DPM, FRANZCP

Summary Comorbid depression and anxiety disorders occur in up to 25% of general practice patients. About 85% of patients with depression have significant anxiety, and 90% of patients with anxiety disorder have depression. Symptomatology may initially seem vague and non-specific. A careful history and examination with relevant investigations should be used to make the diagnosis. Once the diagnosis is made, rating ...

John W G Tiller MD, FRACP, FRANZCP

Summary Depression is usually the predominant phase in bipolar disorder, causes the most psychosocial disability, and carries significant risk of suicide. The management of bipolar depression is relatively under-studied and poses significant challenges for clinicians. There is substantial dissent regarding optimal pharmacotherapy for bipolar depression, particularly around the role of antidepressants. Individual and combination pharmacotherapy should be integrated into a personalised ...

Michael Berk PhD, MB BCh, FRANZCP · Lesley Berk MA(Clin Psych) · Christopher G Davey FRANZCP · Steven Moylan BM BS(Hons), MPH, BSc · Francesco Giorlando MB BS, BMedSc · Ajeet B Singh MB BS, MPsych, FRANZCP · Harish Kalra FRANZCP · Seetal Dodd BSc, MSc, PhD · Gin S Malhi MB ChB, FRANZCP, MD

Summary Depressive symptoms are common in people with schizophrenia and can be associated with suicidality, but are often either missed or dismissed by clinicians. General practitioners have a key role in initial assessment and subsequent monitoring of depressive symptoms, associated risks and physical health in patients with schizophrenia. Liaison with appropriate non-government organisations and public or private specialist mental health services can ...

Peter Bosanac MB BS, MD, FRANZCP · David J Castle MD, FRANZCP, FRCPsych

Summary Depression in people with dementia is a common presentation in primary care, but it is often missed or mismanaged. This problem has substantial public health implications and adversely affects the quality of life and physical health of patients and carers. Many aspects of diagnosis and management remain controversial. A high degree of suspicion and repeated assessment is essential for diagnosis. ...

Eleanor M Curran MB BS(Hons), BMedSc(Hons), MPM · Samantha Loi MB BS, MPM, FRANZCP

Summary In the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial of almost 3000 patients with depression in the United States, 50% responded to the initial trial of a selective serotonin reuptake inhibitor antidepressant, but only a third achieved remission (nil or minimal depressive symptoms). The final remission rate, even after four potential treatment steps, was only 70%. This finding reflects the reality of ...

Herng-Nieng Chan MB BS, MMed(Psych) · Philip B Mitchell AM, MD, FRANZCP, FRCPsych · Colleen K A Loo MB BS(Hons), MD, FRANZCP · Samuel B Harvey MB BS, MRCPsych, PhD

Summary There has been substantial recent interest in novel brain stimulation treatments for difficult-to-treat depression. Electroconvulsive therapy (ECT) is a well established, effective treatment for severe depression. ECT’s problematic side-effect profile and questions regarding optimal administration methods continue to be investigated. Magnetic seizure therapy, although very early in development, shows promise, with potentially similar efficacy to ECT but fewer side effects. ...

Paul B Fitzgerald MB BS, PhD, FRANZCP

Summary Coexisting psychiatric and medical conditions, environmental and contextual factors, inadequate diagnosis and treatment, medication non-adherence, and issues such as low self-esteem, hopelessness and cognitive reactivity, can play a role in difficult-to-treat depression. A reduction in symptoms due to pharmacological treatment does not equate with full recovery, and some level of rehabilitation is often required. The evidence base for psychosocial therapies in ...

Melissa F Casey DPsych, PGDipPsych, GDPsy · Dinali N Perera DPsych, BA, BSocSc(Psych)(Hons) · David M Clarke PhD, FRACGP, FRANZCP