Commentary
A new addition to JFP: “Behavioral Health Consult”
The column will address topics like depression and substance abuse.
Making the most of the tools at your disposal
As a family physician (FP), you are especially well positioned to help patients suffering from MDD by offering education, counseling, and support; prescribing antidepressants; and coordinating care. Collaboration with behavioral health teams may be beneficial, especially in complex and treatment-resistant cases.
Counseling, alone or combined with pharmacotherapy, may improve patient outcomes.16,17 A first step may be recommending behavior modifications (such as adequate sleep, exercise, and a healthy diet). FPs can learn to utilize several counseling techniques, such as motivational interviewing, solution-focused therapy, and supportive therapy, for a variety of clinical situations in which behavioral change would be helpful.18 Establishing a therapeutic alliance through empathy and creating treatment expectations are key to helping patients overcome depression.19,20 Referral to a therapist can help identify and manage psychosocial factors that are often inherent in depression. Explaining to the patient that depression is best improved with a combination of medication and therapy is often helpful in motivating the patient to see a therapist.
Selecting an antidepressant. There is insufficient evidence to show differences in remission rates or times to remission among antidepressants,21 so medication choice involves balancing factors such as cost, previous treatments, adverse effects, and comorbid conditions (TABLE 322). A recent systematic review and meta-analysis involving 66 studies and more than 15,000 patients found tricyclic/tetracyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) to have the best evidence for treatment of depression in the primary care setting.23 Ask the patient about previous antidepressant prescriptions they were given, if any, and weigh the benefits and adverse effects with the patient.
Patients may notice a partial response as early as one to 2 weeks after starting treatment with antidepressants, but it’s important to tell them that a full response can take up to 4 to 6 weeks. The goal of treatment is remission of depressive symptoms, which is defined as scoring below the cutoff point on a validated depression scale, such as less than 5 on the PHQ-9.24 It’s advisable to increase the antidepressant dose if the patient has a partial response and switch to a new class if the patient has no response or severe adverse effects.
Antidepressants should be maintained for at least 6 months or the length of a previous episode, whichever is greater.24 Prophylactic treatment should be considered for patients who have had severe episodes in the past (eg, a history of suicidal ideations and/or past hospitalizations). If an antidepressant is discontinued, it should be tapered over one to 2 weeks to minimize the risk of discontinuation syndrome (flu-like symptoms, nausea, insomnia, and hyperarousal). There is a lack of consistent evidence for the use of St. John’s wort, and as such, it is not recommended.24
Adjunct medications can also be used when remission does not occur after 8 to 12 weeks of maximum antidepressant doses. Insomnia, which is a common complaint in patients with MDD, can be treated with trazodone (an off-label indication), diphenhydramine, or melatonin. (See “Insomnia: Getting to the cause, facilitating relief.”) Benzodiazepines and other hypnotics (eg, zolpidem) can be used initially until antidepressants have had time to become effective. Antipsychotics such as aripiprazole, risperidone, quetiapine, and ziprasidone can be used to treat psychotic symptoms of depression or boost antidepressant effectiveness.25 Lithium and thyroxine are effective for treatment-resistant depression.26 Nutraceuticals such as S-Adenosyl-L-methionine, methylfolate, omega-3, and vitamin D can reduce depressive symptoms when combined with an antidepressant.27
There is some evidence to support combining 2 antidepressants from different classes (eg, an SSRI plus a serotonin–norepinephrine reuptake inhibitor [SNRI] or norepinephrine–dopamine reuptake inhibitor, or an SNRI plus a noradrenergic and specific serotonergic antidepressant) when adjunct therapy has proven ineffective.28
Inpatient psychiatric admission is warranted in severe cases, such as when a patient has active suicidal intentions/plans or poor self-care.
Your critical role, even when depression is co-managed
Collaborative care for depression (patient contact with both primary and behavioral health care providers in the same clinic) significantly improves clinical outcomes at 6 months compared to primary care treatment alone.29 Patients who have failed 2 therapeutic trials (at least 6-8 weeks of separate antidepressant treatments without response) are considered treatment-resistant.30 Referral to a psychiatrist is appropriate in this setting to determine alternative treatment options.
