Treating Depression in Primary Care: The Latest Guidelines

Neil Skolnik, MD


March 21, 2023

This transcript has been edited for clarity.

Today, I'm going to talk about the American College of Physicians clinical guideline on the treatment of depression. Depression is a frequent flyer in primary care. Over a lifetime, 20% of adults experience depression, and about 10% experience it in any given year. These figures have worsened during the pandemic. Approximately 80% of antidepressants are prescribed in primary care.

You want to make sure that the patient has depression, not bipolar disorder. Then gauge the severity of depression — mild, moderate, or severe — depending on the patient's symptoms and functional impairment.

Treatment can have no effect, a partial effect, or a full effect leading to remission. Because the majority of people started on treatment don't achieve full remission, it's important to be comfortable with second-line treatments for those who don't fully respond.

Let's start with the recommendations for treatment of mild depression. Cognitive-behavioral therapy (CBT) is preferred over medication, and that's because there is good evidence that CBT works as well as medication, without any side effects. If CBT isn't available, then second-generation antidepressants (SGA), such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), or other medications (bupropion, mirtazapine), and some of the newer agents are all options. Remember, aerobic exercise helps a lot at improving depression.

The initial treatment of patients with moderate to severe depression is CBT, an SGA, or combination therapy with CBT and an SGA. There is no difference in efficacy between the different SGAs, but there are important differences in side effects. Common side effects of the antidepressants include gastrointestinal side effects, such as constipation, diarrhea, nausea, as well as other side effects, including dizziness, insomnia, fatigue, and sexual dysfunction.

There are some notable differences among the different medicines. The SSRIs often lead to a loss of appetite, sexual dysfunction, and insomnia. Mirtazapine, unlike the SSRIs, can lead to weight gain instead of weight loss and can be sedating, so it's useful for patients who have trouble sleeping at night. Bupropion and mirtazapine are not associated with sexual dysfunction. The SNRIs are good choices for patients with chronic pain, and they seem to have a beneficial effect on people with attentional issues.

Because 70% of people don't achieve a full remission with initial treatment. It's important for us to know the next steps. For second-line treatment, we have some choices we can switch to. We can augment therapy with CBT if we didn't use it initially, switch to a different SGA, or augment what the patient is currently on with a second medication. Usually, that second medicine is going to be mirtazapine, bupropion, or buspirone.

Some general considerations include starting with a low dose of medicine, seeing patients back frequently, and then titrating up to the maximum dose of antidepressant medicine. We should be monitoring for new or increases in suicidal thoughts during the first 1-2 months of treatment. Once remission is achieved with medical treatment, then antidepressant medicine should be continued for at least 4-9 months. If it's not the first episode but a second or third episode of depression, then the medications should be continued longer.

For patients with severe symptoms or those who do not have a full response after second-line therapy, referral to a psychiatrist makes sense and is important because other treatments are available that aren't covered in the guidelines. Those treatments include other adjuvant medicines, transcranial magnetic stimulation, electroconvulsive therapy, ketamine, as well as partial and full outpatient and inpatient programs.

In summary, if possible, start with CBT for patients with mild depression, although SGAs are a reasonable option for people with moderate to severe depression. Use either CBT, an SGA, or both, and then monitor for response. Titrate up the medicines as indicated and don't be afraid to add a second-line treatment (either CBT or a second agent) if it's needed.

I'm interested in your thoughts on this. Please leave them in the comments section.

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