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Treating depression in primary care

Treating Depression in the
Primary Care Setting
MHNet has adopted this guideline from the American Psychiatric Association’s (APA) Practice Guideline for the Treatment of Major Depression. This synopsis is provided as a service to primary care practitioners. This guideline summary is not designed to stand on its own and should be used in conjunction with the full text of the Practice Guideline which is available at the APA’s web site, www. If you do not have access to this web site and would like a hard copy of the complete practice guideline, please contact MHNet’s Corporate Quality Improvement Department at (512) 347-7900. Major depression is a common illness affecting roughly 15 per- INITIATING ANTIDEPRESSANTS
cent of the population at sometime during their life. Most people with major depression do seek professional help. For those who do, pri- The first step is to get a thorough history of medication use and mary care physicians remain the point of entry into the behavioral response. In general, if a patient has shown a clear response to a health system, even when managed behavioral health care organiza- specific agent in the past, the same drug should be restarted. The only exception would be a patient whose prior treatment was in the remote past before the discovery of newer generation antidepressants. Depression presents myriad chal enges to PCP’s. Successful For these individuals, one may elect to try a newer drug with fewer treatment of major depression requires a proactive and systematic side effects than an older tricyclic or monoamine oxidase inhibitor approach to detection and management through a combination of psy- chotherapy and, often, medication. The therapy does not have to be If there is no prior history of antidepressant responsiveness, most sophisticated. Brief supportive therapy is sufficient for many individu- physicians initiate therapy with a selective serotonin reuptake inhibitor (SSRI). There are currently four FDA approved SSRI’s available for the treatment of major depression (Celexa, Paxil, Prozac and Zoloft). Primary care physicians have several functions with regards to Of these, only Prozac currently has a generic substitute. It is recom- major depression: they need to identify patients with the condition, mended that PCP’s become familiar with one or two of these medica- prescribe medications, provide supportive therapy, adjust medications tions and use them as their first line drugs. as necessary, continue maintenance medications if appropriate, refer specific patients for psychiatric evaluation and counseling, and monitor SSRI’s can be started at the full therapeutic dose (20mg/day for Celexa, Paxil or Prozac, 50mg/day for Zoloft). However, many physi- cians start at ½ dose for several days to minimize initial side effects. EVALUATING PATIENTS
After several weeks, if there has been no response, an upward dosage adjustment of 50-100% of the starting dose can be made. If there has It is recommended that all PCP’s have some mechanism for rou- been no significant response within six weeks, an alternative drug tinely screening patients for major depression. This can be formalized should be tried or a referral made to a psychiatrist. by using a screening questionnaire (e.g. PrimeMD), or by routinely including questions about depression in the review of systems. The SUPPORTIVE THERAPY
PCP should be knowledgeable about the cardinal symptoms of de- If the PCP does not refer the patient for counseling, then he or she should provide the patient with supportive therapy. This should include brief visits (15 to 30 minutes) once a week or every other week for the first two months until the patient reports significant improve- CONTINUATION MEDICATION
Once patients report significant benefit from medication therapy, they should continue the antidepressant medication for at least nine months. Patients should be counseled that premature discontinuation of their medication can result in a prompt relapse. Fol ow up visits Since many patients do not spontaneously report these symp- should be based upon the need for continued supportive counseling toms, it is important that the PCP ask direct questions of any patient and the need to insure medication compliance. Most psychiatrists wil who presents with a new onset of vague symptoms that are not clearly see patients once a month for several months after they report signifi- diagnostic of a specific medical condition. cant improvement to encourage continued compliance with treatment. After nine months, patients can be weaned of the SSRI (typically by If the PCP identifies new onset major depression (or a recurrence taking ½ the dose for a month then stopping). Some patients may of major depression in a patient with a prior history), he or she should experience physical withdrawal (particularly with the shorter acting either refer for psychiatric evaluation or initiate supportive counseling Paxil) that may necessitate more gradual withdrawal. Treating Depression in the Primary Care Setting
Patients who have had more than 3 episodes of major depres- Patients should be referred for counseling if they have multiple or sion (or two episodes if the depression was severe) should be consid- severe life stressors in addition to their depressive illness. They ered for maintenance antidepressant therapy. In weighing this deci- should be referred if the depression is profound, overwhelming, and sion, the physician should balance the relatively small risk of long-term brief supportive contact is insufficient. If the depression is negatively drug therapy against the significant risk of recurrent depression. De- impacting the family, counseling may be helpful in addressing their pression is usually quite incapacitating and is associated with signifi- cant mortality due to suicide. Although some clinicians use lower dose for maintenance therapy, as long as the patient reports no significant Patients should be referred for psychiatric assessment if they are side ef ects from their medication, lowering the dose is not warranted. suicidal, psychotic, or possibly in need of hospitalization. They should be referred if they have a secondary psychiatric condition such as CHOOSING A DIFFERENT AGENT
active substance abuse, panic disorder, dysthymia or personality disor- der. They should be referred if there has been no significant improve- Outcome studies suggest that all antidepressants are effective in ment in two months with a single antidepressant (3 months if two about 60% of patients with major depression. Therefore, it is common that a patient will not respond to the first agent prescribed. It is recom- mend that PCP’s become familiar with one or more non-SSRI medica- tions to use as a second line drug. Possible agents include Wellbutrin, This practice guideline is not intended to be construed or to serve Remeron, or Serzone. Wellbutrin should be initiated at a dose of as a standard of medical care. Standards of medical care are deter- 100mg/day and titrated up to 150mg twice a day. Remeron should mined on the basis of all clinical data available for an individual case start at 15mg hs. As needed, one can adjust the dose up to 45mg hs. and are subject to change as scientific knowledge and technology Serzone is usually started at a low dose (100mg/day) and gradual y advance and patterns evolve. These parameters of practice should be increased to 300-450mg/day in divided doses or all at bedtime. considered guidelines only. Adherence to them will not ensure a suc- cessful outcome in every case, nor should they be construed as includ- CONCOMMITTENT MEDICATIONS
ing all proper methods of care or excluding other acceptable methods of care aimed at the same results. The practitioner, in light of the clini- Antidepressants take several weeks before there is significant cal data presented by the patient and the diagnostic and treatment benefit. Therefore, it is frequently beneficial to give patients some im- options available, must make the ultimate judgment regarding a par- mediate symptomatic relief with anxiolytics during the day (Ativan, ticular clinical procedure or treatment plan. Xanax or Serax) and hypnotics at night for sleep (Ambien, Sonata, Restoril). These should be for short-term use only (2-4 weeks). Since REFERENCES
most of these drugs are short acting, patients should be advised about rebound anxiety when they wear off. In particular, the short acting These guidelines were adapted from the American Psychiatric hypnotics (Ambien and Sonata) may not provide prolonged sleep for Association’s practice guidelines [American Psychiatric Association: Practice Guidelines the Treatment of Patients with Major Depressive Disorder. Am J Psychiatry 2000; 157 (April suppl)]. The reader is re- ELDERLY PATIENTS
ferred to the original article for detailed references as wel as the work Special consideration needs to be given to elderly patients. This includes increased sensitivity to antidepressant side effects especially sedation, agitation, unsteadiness, and confusion. Possible interactions with other medications should be considered before initiating therapy. Starting doses should be adjusted downward. One typically starts with ½ the usual starting dose of an antidepressant, ¼ the usual starting dose of an anxiolytic. The possibility of a medical condition causing or exacerbating the depression is increased in the elderly population. Therefore, one must be sure to exclude any underlying treatable physi-cal condition. MHNet Behavioral Health


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