Brief Treatment Strategies for Major Depressive Disorder: Advice for the Primary Care Clinician

Ivan Valdivia, PhD Candidate; Nadine Rossy, BAC, PhD Candidate

Topics in Advanced Practice Nursing eJournal. 2004;4(1)

Abstract

Major depressive disorder (MDD) is a common chronic and debilitating, but highly treatable, affective disorder. In the current climate of managed care, which limits the number of sessions and the type of treatment that can be provided, it has become important for clinicians to identify how they can best fulfill this mandate. There are many evidence-based treatments available to clinicians, including pharmacotherapy and psychotherapy, but patient preference, clinician availability, and time limitations often dictate the treatment approach. This article describes several behavioral techniques that can be easily adapted by primary care advanced practice nurses and other clinicians in order to provide brief but effective treatment to depressed patients. These techniques include: behavioral activation, guided self-management, and treatment adherence monitoring. The application of appropriate, evidence-based treatments by primary care clinicians will maximize the number of people effectively treated for MDD and relieve some of the strain on the healthcare system.

Karen, 32 years of age, presents to her primary care provider with complaint of chronic pain related to a previous back injury. She appears quiet and shy. In addition to the constant low backache, she reports feeling sad most days and has lost considerable interest in many of the activities that she once enjoyed, such as skiing and painting. She describes having difficulty concentrating at work and feeling guilty about many things that she does and has not done. In addition, she is complaining of having a poor appetite and having problems staying asleep. She reports that these symptoms are reduced on days she has less pain, but over the past 2 weeks, her symptoms have remained constant.

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Table 1. Diagnostic Interview Questions for Depression
Symptom	Question
Sadness	Have you been feeling sad, blue, down, or depressed?
Anhedonia	Have you lost interest in or do you get less pleasure from doing the things you used to enjoy?
Appetite	Has there been any change in your appetite? Have you gained/lost any weight?
Sleep	How have you been sleeping?
Psychomotor	Have you been more fidgety and having problems sitting still? Have you felt slowed down, like you were moving in slow motion or stuck in mud?
Energy	Have you been feeling tired or worn out?
Self-esteem	Do you feel like you're worthless or a failure? Do you feel guilty?
Cognitive	Have you been having problems thinking or concentrating? Is it harder to make decisions than before?
Suicide	Sometimes when a person feels down or depressed they might think about dying. Have you thought about taking your life?

Note: For each symptom, intensity, duration, and persistence must be assessed.
Adapted from Zimmerman M. Interview Guide for Evaluating DSM-IV Psychiatric Disorders and the Mental Status Examination. East Greenwich, RI: Psych Product Press; 1994.

Table 2. Online and Offline Resources on Depression
Fact Sheets for Patients: Canadian Psychological Association https://www.cpa.ca/factsheets/depression.htm (brief) https://www.psych.org/psych_pract/treatg/patientfam_guide/MajorDepressive.pdf (in-depth) Medscape's Depression Patient Education Center https://www.medscape.com/pages/editorial/patiented/index/index-depression
Mental Health Resource Book for Nurses: Russell G. Essential Psychology for Nurses and Other Health Professionals. London: Routledge; 1999.
Quick Reference Article for Assessing and Treating Depression: https://www.psych.org/psych_pract/treatg/quick_ref_guide/major_depressive_disorder_qrg9402.pdf
Web sites National Depressive and Manic-Depressive Association https://www.dbsalliance.org National Institute of Mental Health -- NIMH https://www.nimh.nih.gov/publicat/depressionmenu.cfm National Foundation for Depressive Illness https://www.depression.org Medscape's Depression Resource Center for Professionals https://www.medscape.com/pages/editorial/resourcecenters/public/depression/rc-depression.ov
Psychotherapy Treatment Manuals: Burns D. The Feeling Good Handbook (Revised Edition). New York: Avon Books; 1999. Emery G. Overcoming Depression: A Cognitive-Behavioral Protocol for the Treatment of Depression. Oakland, Calif: New Harbinger Publications; 2000. Lejuez H, Hopko DR, Hopko, SD. A brief behavioral activation treatment for depression: treatment manual. Behav Mod. 2001;25:255-286. Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES. Interpersonal Psychotherapy of Depression. New York: Basic Books; 1984.

Table 2. Online and Offline Resources on Depression
Fact Sheets for Patients: Canadian Psychological Association https://www.cpa.ca/factsheets/depression.htm (brief) https://www.psych.org/psych_pract/treatg/patientfam_guide/MajorDepressive.pdf (in-depth) Medscape's Depression Patient Education Center https://www.medscape.com/pages/editorial/patiented/index/index-depression
Mental Health Resource Book for Nurses: Russell G. Essential Psychology for Nurses and Other Health Professionals. London: Routledge; 1999.
Quick Reference Article for Assessing and Treating Depression: https://www.psych.org/psych_pract/treatg/quick_ref_guide/major_depressive_disorder_qrg9402.pdf
Web sites National Depressive and Manic-Depressive Association https://www.dbsalliance.org National Institute of Mental Health -- NIMH https://www.nimh.nih.gov/publicat/depressionmenu.cfm National Foundation for Depressive Illness https://www.depression.org Medscape's Depression Resource Center for Professionals https://www.medscape.com/pages/editorial/resourcecenters/public/depression/rc-depression.ov
Psychotherapy Treatment Manuals: Burns D. The Feeling Good Handbook (Revised Edition). New York: Avon Books; 1999. Emery G. Overcoming Depression: A Cognitive-Behavioral Protocol for the Treatment of Depression. Oakland, Calif: New Harbinger Publications; 2000. Lejuez H, Hopko DR, Hopko, SD. A brief behavioral activation treatment for depression: treatment manual. Behav Mod. 2001;25:255-286. Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES. Interpersonal Psychotherapy of Depression. New York: Basic Books; 1984.

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