Treatment of mental disorders has increased substantially over the past decades, yet a majority of adults with mental disorders do not receive treatment at all, or do not receive treatment in accordance with accepted standards of care. For minority populations, rates of high-quality mental health treatment are even lower.
Selection of an initial treatment modality should be influenced by both clinical factors (eg, severity of symptoms) and patient preference. In general, evidence-based recommendations for treatment of moderate to severe depression in the primary care setting involves a combination of pharmacotherapy and psychotherapy, and for the treatment of mild to moderate depression, psychotherapy or pharmacotherapy alone.
Although the majority of depressed patients are treated in primary care settings, some cases are especially difficult to manage in general medical clinics without specialized services. Specialized psychiatric care is strongly indicated if clinical findings support a diagnosis of psychotic depression, bipolar disorder, active suicidal ideation, depression with comorbid substance abuse, depression with comorbid dementia, treatment-resistant depression, and other needs for a more specialized assessment.
A. Psychotherapeutic Interventions
For patients with mild to moderate major depressive disorder, psychotherapy alone may be appropriate. Cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) are evidence-based psychotherapeutic approaches used in the treatment of patients with major depressive disorder. Factors to consider when determining how often to see an individual patient include the goals of the psychotherapy, the frequency necessary to create and maintain a therapeutic alliance, the frequency required to ensure treatment adherence, and the frequency necessary to monitor and address suicidality. Often, if a skilled therapist is not available in the primary care setting, referral to a mental health specialist may be indicated (eg, psychiatric nurses, licensed clinical social workers, psychologists, or psychiatrists). Primary care providers should ensure that patients are made aware of psychotherapy as an option and that they are assisted in accessing psychotherapeutic interventions.
Antidepressant medications may be initiated for treatment of patients with mild symptoms of major depressive disorder, and should be initiated for all patients with moderate to severe symptoms. Improvement should be noted within 6–8 weeks of initiating therapy, and the goal of antidepressant therapy is to achieve full remission of depressive symptoms. Studies have shown that maintenance antidepressant therapy is effective in preserving improvements and preventing recurrent depression.
The most commonly used antidepressant mediations are listed in Table 56-2. Selective serotonin reuptake inhibitors (SSRIs) are usually first-line therapy, due to greater tolerability and equal efficacy compared to other antidepressants. Other medications likely to be optimal for most patients include nortriptyline, bupropion, venlafaxine, and duloxetine. Because of their potential to cause serious side effects and the need for dietary restrictions, monoamine oxidase inhibitors (MAOIs) are typically reserved for patients with treatment-resistant depression.
Table 56-2.Medications used in treatment of depression.a ||Download (.pdf) Table 56-2.Medications used in treatment of depression.a
|Drug Type: Brand (Generic) ||Typical Dailyb Dosage (mg) |
|Selective Serotonin Reuptake Inhibitors (SSRIs) |
Paxil CR (paroxetine, controlled-release)
Prozac Weekly (fluoxetinec)
|Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) |
Effexor XR (venlafaxine, extended-release)
Wellbutrin, Wellbutrin XL (bupropionc)
Wellbutrin SR (bupropion, sustained-releasec)
Aventyl, Pamelor (nortriptylinec)
|Monoamine Oxidase Inhibitors (MAOIs) |
Emsam skin patch (selegiline)
Patients prescribed antidepressant medication should be monitored to assess their response to pharmacotherapy as well as side effects and adverse reactions. After dosing antidepressant medication at the recommended starting dose, it is important to increase the medication over time to an efficacious dose. Few patients treated for depression in primary care reach the recommended therapeutic dosage of the medicine. Screening tests can be used to objectively monitor a patient’s progress throughout treatment. To maintain consistency with clinical practice guidelines, patients should be seen for follow-up after initiating pharmacological treatment within 2–4 weeks. If no response is seen within the initial 6-8-week period of pharmacological therapy, referral for specialty mental healthcare may be considered.
Stepped-care models have been used in primary care settings to manage diverse conditions such as hypertension, and have been shown to be effective in improving the quality of depression care for patients in primary care settings. Stepped-care models are systematic procedures based on using the most effective, but least intensive, treatment for patients, which includes detailed monitoring and tracking of patients’ response to interventions. An example of a stepped-care model for depression treatment is shown in Table 56-3.
Table 56-3.Stepped-care model of depression treatment. ||Download (.pdf) Table 56-3.Stepped-care model of depression treatment.
|Step 1: All known and suspected presentations of depression ||Assessment, support, psychoeducation, active monitoring, and referral for further assessment and interventions |
|Step 2: Persistent subthreshold depressive symptoms, mild to moderate depression ||Low-intensity psychological and psychosocial interventions, medication, and referral for further assessment and interventions |
|Step 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression ||Medication, high-intensity psychological interventions, combined treatment, collaborative care, and referral for further assessment and interventions |
|Step 4: Severe and complex depression; risk to life; severe self-neglect ||Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care |
C. Complementary/Alternative Therapies
Some studies show a beneficial effect of exercise programs in treatment of depression in comparison to antidepressant medication alone. Meditation-based cognitive therapy has been shown to be effective for treatment of and decreasing recurrence of major depressive disorder. A variety of coping and self-management strategies can also be helpful, such as peer support, exercise, good nutrition, progressive muscle relaxation, setting aside time for pleasurable activities, and setting small, achievable goals. Furthermore, increasing evidence in the medical literature supports the beneficial role of spirituality in the health of patients.
St. John’s wort has been used to treat depression for many years, and multiple randomized clinical trials have demonstrated its effectiveness in the treatment of mild to moderate depression. However, St. John’s wort has increased medication interactions, particularly in older adults, and is generally not recommended for treatment of depression in most populations. Interactions between St. John’s wort and antidepressants are concerning, especially considering that patients are often less likely to share information about herbal supplements that they are taking when discussing their current medications.
Other alternative medication therapies have conflicting reports about efficacy, but include S-adenosyl methionine (SAM-e), omega-3 fatty acids, and folic acid supplementation; however, further research is needed to determine their efficacy in the treatment of depression.
The combination of psychotherapy and medication is recommended for patients with moderate to severe depression. Patients who have a history of only partial response to adequate trials of either treatment modality alone may benefit from combined treatment. Sequential treatment of psychotherapy and pharmacotherapy may also be beneficial. Patients with poor adherence to individual treatments may also benefit from combined treatment of any form.
E. Electroconvulsive Therapy
Electroconvulsive therapy (ECT) remains a highly stigmatized treatment modality, but it is an evidence-based, effective therapy for depression, particularly among older adults and patients with psychotic or treatment-resistant depression. Patients often have rapid improvement of symptoms of depression, and usually receive two to three treatments per week for 3–6 weeks. Primary care providers should consider a referral to a mental health specialist for evaluation for ECT in patients who have not responded to multiple trials of medication and psychotherapy.
F. Integrated/Collaborative Care Models
Integrated care and collaborative care models have effectively improved the treatment of depression in primary care settings. An extremely well-studied model of using integrated care to treat depression in older adults is the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. The IMPACT model has shown significantly better outcomes for treatment of depression in older adults compared to the usual care. The model embeds a depression care manager (supervised by a psychiatrist and primary care expert) in a primary care setting to provide comprehensive services to older adults with depression.
Integrated care models have shown particular efficacy among older adults, who are more likely to accept treatment for depression in primary care settings rather than in specialty mental health settings. Within diverse populations, integrated care/collaborative care models have also shown efficacy in African American and Hispanic populations, but further research on additional racially/ethnically diverse populations is needed.
G. Addressing Disparities and Cultural Differences in Depression Care
Studies have shown that different racial and ethnic groups, as well as different age and gender groups, experience and communicate symptoms of depression differently and prefer different forms of treatment. If the provider does not speak the patient’s native language, a well-trained healthcare interpreter should be used to ensure that accurate information is exchanged. Some minority populations are more receptive to psychotherapy than pharmacotherapy, and patient preferences should be explored in order to practice cultural competence. Because stigma continues to be a pervasive barrier to seeking appropriate mental health treatment, primary care providers should encourage open dialog and help correct any false assumptions about the origins of mental health problems and judgments about individuals with mental health problems.
Patient-provider communication is critical to diagnosis and treatment. The physician should elicit patients’ explanatory models (what patients believe is causing their illness) and agendas (what patients seek from treatment), the role of family members in their lives, how those family members will react to the patient being treated, and how patients perceive treatment. For some people, experiences of racism and prejudice may leave people suspicious of diagnoses that do not require radiologic or laboratory examinations. The provider must use excellent communication skills to convey humility, empathy, respect, and compassion, as these are important factors in securing an accurate diagnosis and effective treatment of depression in racially, ethnically, and culturally diverse populations (See Table 56-4).
Table 56-4.Factors affecting cultural competence in assessment, diagnosis, and treatment of depression. ||Download (.pdf) Table 56-4.Factors affecting cultural competence in assessment, diagnosis, and treatment of depression.
Recognition of language differences
Health literacy barriers
Use of cultural idioms of distress
Non-Western context of mental illness and treatment
Individually tailored treatment plans
Spirituality is often an important determinant of mental health. The mere presence of a religious affiliation and the saliency of a person’s religion have been shown to provide a strong defense against depression and suicide, particularly in older adults with medical illnesses or disability. This is important for providers not only because it may largely influence how patients cope with their illnesses, but also because studies have shown that validating this aspect of a patient’s life and incorporating it into treatment plans can positively affect the patient’s adherence to treatment and even accelerate rates of remission.
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