REVIEW ARTICLE
DEPRESSION IN PRIMARY CARE
PART 2: MANAGEMENT
Therapeutic Considerations
Symptoms of depression do not start to resolve until the patient has received an adequate dose of medication for a period of two to four weeks and full remission of symptoms may take up to four months. Patients who feel better or well often discontinue antidepressant treatment prematurely. International guidelines for the management of depression recommend that patients with a first episode depression should continue to use antidepressant treatment for six months from the point of full remission of symptoms.4 The other principle is ‘the dose that makes the patient well keeps the patient well’. Thus, the patient has to be on an adequate dose of antidepressants for an adequate period of time. Relapses can occur if antidepressant treatment is discontinued or if the dose of the antidepressant is reduced prematurely. Recurrent episodes of depression require longer periods of treatment. A second episode of illness may require up to two years of antidepressant treatment and three or more episodes signal an indefinite period of pharmacotherapy.
If a patient does not respond to an adequate trial of antidepressants, a switch to an antidepressant of a different chemical class should be contemplated. Augmentation can be tried with mood stabilisers like lithium, valproate or lamotrigine.7
In treating the elderly depressed one has to use the tenet, ‘start low and go slow’. Treatment should begin with low doses of antidepressants, slowly titrated upwards to an adequate dose.
PSYCHOLOGICAL INTERVENTIONS
Evidence shows that the two most effective therapies for depressive disorders are Cognitive Behavioural Therapy (CBT) and Interpersonal Psychotherapy (IPT).4,9,10 These therapies require about 12 to 16 sessions to bring about a significant reduction of symptoms and each session may last from 45 minutes to an hour. Furthermore, the doctor has to be trained under supervision in order to institute this therapy. These pose serious challenges to primary care physicians. Simple interventions based on techniques used in CBT and IPT like ‘encouragement of affect’, ‘distraction’, ‘problem solving’ and ‘scheduling activities in a graded manner’ have proven to be effective in primary care.2 These techniques are not time consuming and easy to learn. The physician can conduct the interventions during consultation and the patient can use them to help him- or herself outside consultation.
Problem solving is effective in tackling problems related to interpersonal issues such as relationships at home and at work. The following are guidelines for problem solving:
- Identify the problem area with the patient
- Prioritize and choose one problem if there are more than one
- Brainstorm for options or possible solutions to the problem
- Choose a preferred option or solution
- Work out steps to tackling the problem using the option
- The patient is to carry out the task (the steps)
- Review the implementation of the task
- Decide next steps depending on progress made
Encouragement of affect allows the patient to express his/her emotions and the content linked with these emotions. An example would be a patient who sheds tears and expresses sadness and talks of being verbally and emotionally abused by her husband to her empathetic physician.
‘Distraction’ enables the patient to distract attention from the pessimistic thoughts that are part of the cognition of a depressed person. For example, a depressed man who normally enjoys tinkering with his car is encouraged to do so when he is preoccupied with negative thoughts. This helps him focus his thoughts on the car and draws attention away from the pessimistic thoughts.
Scheduling activities in a graded manner helps the patient resume activities that she or he normally undertakes but has stopped doing because of the illness. ‘Scheduling’ instils regularity whereas ‘grading’ builds competency by encouraging the completion of a simple task followed by the undertaking of more complex activities.
