Summary
Depression is one of the most common conditions in primary care, but is often unrecognized, undiagnosed, and untreated. Depression has a high rate of morbidity and mortality when left untreated. Most patients suffering from depression do not complain of feeling depressed, but rather anhedonia or vague unexplained symptoms. All physicians should remain alert to effectively screen for depression in their patients. There are several screening tools for depression that are effective and feasible in primary care settings. An appropriate history, physical, initial basic lab evaluation, and mental status examination can assist the physician in diagnosing the patient with the correct depressive spectrum disorder (including bipolar disorder). Primary care physicians should carefully assess depressed patients for suicide. Depression in the elderly is not part of the normal aging process. Patients who are elderly when they have their first episode of depression have a relatively higher likelihood of developing chronic and recurring depression. The prognosis for recovery is equal in young and old patients, although remission may take longer to achieve in older patients. Elderly patients usually start antidepressants at lower doses than their younger counterparts.
Most primary care physician can successfully treat uncomplicated mild or moderate forms of major depression in their settings with careful psychiatric management (e.g., close monitoring of symptoms, side effects, etc.); maintaining a therapeutic alliance with their patient; pharmacotherapy (acute, continuation, and maintenance phases); and / or referral for psychotherapy. The following situations require referral to psychiatrist: suicide risk, bipolar disorder or a manic episode, psychotic symptoms, severe decrease in level of functioning, recurrent depression and chronic depression, depression that is refractory to treatment, cardiac disease that requires tricyclic antidepressants treatment, need for electroconvulsive therapy (ECT), lack of available support system, and any diagnostic or treatment questions.
Antidepressant medications’ effectiveness is generally comparable across classes and within classes of medications. The medications differ in side effect profiles, drug-drug interactions, and cost. The history of a positive response to a particular drug for an individual or a family member, as well as patient preferences, should also be taken into account. Most psychiatrists agree that an SSRI should be the first line choice. The dual action reuptake inhibitors venlafaxine and bupropion are generally regarded as second line agents. Tricyclics and other mixed or dual action inhibitors are third line, and MAOI’s (monoamine oxidase inhibitors) are usually medications of last resort for patients who have not responded to other medications, due to their low tolerability, dietary restrictions, and drug-drug interactions. Most primary care physicians would prefer that a psychiatrist manage patients requiring MAOI’s.
Psychotherapy may be a first line therapy choice for mild depression particularly when associated with psychosocial stress, interpersonal problems, or with concurrent developmental or personality disorders. Psychotherapy in mild to moderate depression is most effective in the acute phase, and in preventing relapse during continuation phase treatment. Psychotherapy is not appropriate alone for severe depression, psychosis, and bipolar disorders. For more severe depression, psychotherapy may be appropriate in combination with the use of medications. The most effective forms of psychotherapy are those with structured and brief approaches such as cognitive behavioral therapy, interpersonal therapy, and certain problem solving therapies. Regardless of the psychotherapy initiated, “psychiatric management” must be integrated at the same time.
Patients, who live with depression, and their family and friends, have enormous challenges to overcome. Primary care physicians can provide compassionate care, important education, psychiatric monitoring, social support, reassurance, and advocacy for these patients and their loved ones.
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