COMMENTARY

Managing Depression in Primary Care: A Step-by-Step Guide

Stephen M. Strakowski, MD

Disclosures

September 10, 2015

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A Patient in Your Office With Depression

I'm Stephen M. Strakowski, a professor of psychiatry, psychology, and biomedical engineering at the University of Cincinnati (UC), and also a senior vice president and chief strategy officer for the affiliated health system, UC Health. Today I'm going to talk about the management of major depressive illness.

Depression is one of the most common conditions facing human beings. Its lifetime prevalence is as much as 15% of the population. It strikes all age and socioeconomic groups, and it's so common that most depression will be treated by default by nonpsychiatric physicians. Frankly there aren't enough psychiatrists around to meet the large demand for treatment of depression.

Key Components of Management

In facing a patient in your office with depression, there are seven key components to think about as you start working with that person. These are listed in Figure 1.

Figure 1. Seven key components of depression management.

These seven key components are comprehensive assessment, ongoing safety evaluations, setting treatment goals, agreed-upon treatment plan to meet the goals, creating a good support network, mood charting, and systematic and meaningful appointments. We will talk about the last component towards the end of this discussion, but it becomes particularly important in busy primary care practices.

What do I mean by a comprehensive assessment? It is something that each practice should develop. Psychiatrists often do this routinely, but in primary care offices this assessment may need to be done through a medical assistant or patient-administered questionnaire. It should be some type of systematic psychiatric assessment. Some checklists that elicit depressive symptoms, such as a PHQ9 [Patient Health Questionnaire-9] or a QIDS [Quick Inventory of Depressive Symptomatology], have a list of psychiatric conditions that the person has experienced or which run in his or her family.

Along with the depression inventory, you need to do a good medical review of systems. There is good evidence that patients with psychiatric diagnoses receive substandard medical care, so don't forget to conduct a good medical evaluation. These assessments are important because depression has a number of heterogeneous causes related to underlying conditions. Family history becomes important for recognizing heritable conditions that might require more complex treatment, such as a family history of bipolar disorder. In such a case, the nonpsychiatrist may even consider a fairly quick referral because of the potential complexity of managing the condition. Assessing stressors is often not done in general medical practice, but it becomes important when assessing depression because stress is a common, underlying precipitant—if not cause—in many cases of depression.

Don't forget about drugs and alcohol. Alcohol is a depressogenic drug in and of itself, and so are many other sedative drugs, including marijuana. Smoking is often not considered, but smoking is associated with an increased risk for anxiety, which increases the risk for depression. Smoking seems to increase suicidality independent of depression, so it becomes a very relevant comorbidity.

Assessing Suicide Risk

A suicide assessment at baseline is important to identify potential risk factors and protective factors. A checklist while the person is waiting to be seen can accomplish a lot of this assessment. But to be certain, you should talk about it. There is no risk in talking about suicide, and not doing so can make the patient hesitate to bring it up to you later.

In assessing risk for suicide, several important risk factors predict a higher relative rate of suicide. Unfortunately, no one has yet figured out how to truly predict suicide in a given individual, so these become assessments of relative risk and need to be weighed within the context of other factors. The strongest predictive factor for a suicide attempt is a previous suicide attempt. A family history of suicide may also increase the risk for suicide. Talking about suicide or talking about feeling hopeless is sometimes a risk factor for suicide. Drug and alcohol abuse (particularly acute intoxication) increases the risk for suicide, as do comorbid psychiatric and medical disorders. The suicide rate in men declines after an initial increase in the late teens and early 20s, and then steadily rises through most of the rest of the adult's life. Being an older patient is a risk factor for suicide.

Protective factors are a supportive environment of family and children, a religious background that precludes suicide as an option, strong social support, a lot of future-oriented talk, good coping skills, and good mental health care. As we make that initial assessment and then an ongoing assessment, it is important to try to minimize risk factors and maximize protective factors.

Setting Treatment Goals

Once we are working toward treatment, we want to set realistic treatment goals with our patients. Share the results of your evaluation, including your concerns about suicide and the risk factors and protective factors, so that the family and patient can participate. Identify the potential contributors to continuing depression and understand what the person is hoping to get out of treatment. This will become important in treatment planning. If the person's goal is just to get rid of symptoms and he or she is not particularly worried about function, then a medication may be a better choice.

But if there are considerable functional or cognitive concerns or interpersonal issues that are causing stressors, medications won't fix those and therapy may become more important. Understand how these treatments work and that they don't work immediately. Antidepressants, for example, take at least 3 weeks for any effect. Robust effects don't occur for 3-6 weeks, with full effects as late as 12 weeks. If we suggest that patients can start a drug today and that the next day they are going to feel better, they are going to have unrealistic expectations and will stop treatment. Conversely, if we don't give them hope of some kind of early response, they may give up.

Identify measures that will show that the patient is actually better. This may be simply returning to function, the ability to sleep, or not feeling sad every day. But for people who experience recurrent symptoms or who have complex life situations, different kinds of measures may be more useful. Once we have set the goals and developed a treatment plan, the first decision point is whether there is a fairly clearly related cause that can be managed, such as a medical illness or a specific acute stressor. That decision is whether to simply manage the other illness or stressor, and hope that doing so resolves the depression.

Specific Treatment for Depression

If there is no suicidal thinking and the person is functioning, it is a reasonable first step to manage the potential precipitant before initiating additional treatment. In that case, once the contributing event is being managed and the symptoms are not improving, a fairly low threshold should be used to initiate specific antidepressant treatment. There are really three choices to make then. One is to initiate psychotherapy alone. Some evidence-based psychotherapies (such as cognitive-behavioral therapy) are very effective, particularly in mild to moderate depression.

The second choice is an antidepressant alone. The antidepressants are shown to have a response rate of 60% to 70% in uncomplicated depression and work across the spectrum of severity. The final choice is a combination of the two, which is typically more effective but also has more associated time and cost, which must be balanced. If the depression is very severe or the patient has psychotic components and significant suicidality, nonpsychiatrists should refer that patient either for inpatient therapy or a psychiatric evaluation right away, because other kinds of treatments come into play, such as electroconvulsive therapy or perhaps antipsychotics.

In a typical practice, however, once you have established that it is appropriate to manage the patient as an outpatient and treatment is initiated, my recommendation is to see the patient within about 2 weeks and continue visits at about 2-week intervals until some progress is clearly being made. The shorter intervals are often different from those in typical primary care practices, but they become very important, particularly in younger patients, because there is evidence in teenagers and young adults that antidepressants are associated with increased agitation, which in turn may be associated with increased risk for suicide.

Support and Follow-up

The best way to manage that is to have regular follow-up visits. Once people are responding and functioning better, then those visits can be spaced out. It's also worth thinking about having a 30-minute visit, at least initially, which is common in psychiatric practice. It is what I typically do in my practice for most patients but is a bit longer than a visit in a typical busy primary care practice. It may be worth blocking out that extra time, at least for the first couple of visits, to just make sure everything is going well.

A common reason for treatment failure in the early period is that many nonpsychiatrists start with too low a dose of antidepressant and aren't aggressive enough in raising the dose. Make sure you understand the antidepressants that you are using, and then use them as aggressively as they can be tolerated. I recommend that nonpsychiatrists become familiar with two different classes of antidepressants, and that you become facile with those to help patients with depression.

It is important to make sure that patients have a good support network—some support from family or friends. There are a couple of good national support groups that have local chapters: The Depression and Bipolar Support Alliance (DBSA) and the National Alliance for Mental Illness. Both of these organizations have groups that can help provide peer support in structured support settings.

Monitoring Mood

Here is a sample of a mood chart (Figure 2).

Figure 2. Mood chart. Courtesy of Stephen M. Strakowski, MD.

These can be very simple. You can get a nice, 6-month personal calendar from DBSA that patients can carry around with them or place by their bedsides. There are apps that allow patients to make mood measurements on their calendars. The point is to have some kind of measure every day for how mood symptoms and depressive symptoms are responding to treatment. I usually ask people to rate the worst level that the depression was at the end of the day for each day, and you will then see a curve with some ups and downs and irregularities in response, which allows you to see whether over time there is general improvement.

The reason why I do this is that human beings tend to report how they have been doing for a long period of time based on how they are feeling at that specific moment, so if patients have had several very good days and then a very bad day on the day of their appointment, they will report that they are doing poorly, and the converse can also be true. The mood chart can help you see that these were exception days and that the treatment should either be retained as it is currently or changed based on more complete data.

When I work with patients I talk about how important these charts are for me, as their physician, to make the best decisions for them. If you design it to be done once a day at bedtime, I find that most people are more than willing to comply with this when they are not feeling well. As they get well, unless they have been well for a while, the compliance falls off, but then it also becomes less important at that point.

The Meaningful Appointment

This figure outlines a meaningful appointment (Figure 3).

Figure 3. Elements of a meaningful appointment.

There are several steps here. You always want to be friendly, but in limited appointments try to minimize chit-chat so we can get the key information that we need in primary care practices, where appointments are short, by self-reports and mood charts. Review the mood chart first because that is a lot of information and really helps you decide whether the treatment is working. Assess suicidality, protective factors, and risk factors; do a quick review of systems (often built into the electronic medical record these days); review adherence (which I often have patients note on the mood chart); and teach patients that when they miss medications their symptoms often worsen, and that when they take them they tend to do better.

Ask about side effects, particularly embarrassing ones. Sexual dysfunction is very common with selective serotonin reuptake inhibitor antidepressants, but many patients will never spontaneously report those effects. They will, however, notice that they are having problems and disappear from treatment if you don't talk to them about it. Support general health measures—exercise, good diet, and good sleep, all of which will help improve a depressed patient. Review drug and alcohol use, and then encourage reduced or no use during depressive periods. Review progress toward goals, provide evidence-based treatments, and dose aggressively. If you are not a psychiatrist and you are faced with a patient who is failing treatment, and you have made a good trial, then maybe that is the time to make a referral to a psychiatrist.

I strongly recommend physicians in general to challenge themselves when they are using more than three medications for virtually anything, because for most conditions (except for some cancer trials and other areas) there just aren't much data about multiple drug combinations and polypharmacy. Anything that is crossing the blood-brain barrier almost certainly has a risk of increasing depression. Finally, leave some time at the end of the visit for questions. So, particularly early in treatment, these are often 30-minute, rather than 15-minute, appointments.

I hope this is helpful to you as you practice. Much of this is better described in more detail in a book[1] that I and a colleague, Dr Nelson, recently published through the Oxford University Press. Thank you for your time and attention today. I am Stephen Strakowski. Have a good day.

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