The United States continues to struggle to provide mental health care to our citizens. The burden of mental health often falls onto emergency rooms, EMT’s and police services. Our responsibility, as primary care providers, is to offer early intervention and treatment to prevent these crises and improve the quality of life. Commonly, we address major depressive disorder. We must recognize and diagnose depression, educate the patients on their diagnosis, and create a treatment plan with their input. We are talking about mild to moderate unipolar depression cases. Patients reporting suicidal ideation: REFER TO EMERGENCY SERVICES. Never take on more than you can handle.
Frequently, patients come in and tell their PCP that they are depressed. We are all familiar with self diagnosis, and know this is not always accurate. The textbook hallmarks of a depression diagnosis are anhedonia, changes in eating/sleeping patterns and depressed mood. Patients won’t come in complaining “I’ve been feeling ‘anhedonial’ lately.” Typically it comes as complaints of fatigue, poor concentration or “not feeling myself.” Remember your differential diagnoses! Bipolar disorder, grief reactions, and adjustment disorders can present in similar ways, but can be treated differently than unipolar depression.
Education is crucial. Many don’t fully understand their diagnosis and depression is not simply feeling sad. Educating patients to understand issues including fatigue, memory/mentition or weight changes can be indications of depression. Depression is a very common issue, but patients feel often embarrassed and lonely in this diagnosis. Many people within patients’ social circles suffer from similar issues, yet many won’t talk about it openly. Reassure them we can address/treat symptoms safely to get them feeling like themselves again.
Treatment is multifaceted and varies depending on the severity of symptoms and patients’ inputs. Patients may be hesitant to take medication. Therapy and counseling is very effective with or without medication. It helps patients address stressful aspects of their life and issues that can worsen their symptoms. Diet and exercise are also key. Regular exercise and balanced diets can lead to increased energy, decreased depressive symptoms and feelings of improved overall well-being.
Inevitably, medication will be part of many treatment plans. Address distrust and stigma of mental health medications, reassure the patient that these medications are safe. They do not change a person’s fundamental self or personality, and make people with depression feel more like themselves. SSRI’s are the first line, because they are well studied and safe. No SSRI has been found to be more effective than another, and efficacy is patient-specific. Educate the patient that medications take time to work, up to 8 weeks to get the full effects. Start with a low dose. Then, bring them back in 2 weeks to see if any changes are noticed. If not, this is a good time to bump up to the next dose. If no changes are noted 4 or more weeks after initiation it may be time to try another SSRI or SNRI. When discontinuing therapy, taper these medications slowly to avoid side-effects. Paroxetine has a short half life leading to more prominent effects upon discontinuation and fluoxetine has one of the longest half-lives and, typically, less issues when tapering and discontinuing medication (1,2,3,4).
That is the tip of the iceberg when dealing with depression as a PCP provider. This is by no means a comprehensive or definitive guide to treatment. This is a good place to start. The steps of proper diagnosis, education and a multifaceted treatment plan can increase chances of success with patients. Our ability to listen and comfort patients with depression, and all other diagnoses, are key to not only helping people, but creating a safe and trusting healthcare environment for the future.
1.The American Psychiatric Publishing Textbook of Psychopharmacology, 4th edition. Schatzberg AF, Nemeroff CB (eds); American Psychiatric Publishing, Inc. Washington, D.C. (2009).
2.Labbate LA, Fava M, Rosenbaum JF, Arana GW. Drugs for the treatment of depression. In: Handbook of Psychiatric Drug Therapy, 6th ed, Lippincott Williams and Wilkins, Philadelphia 2010. p.54.
3.Gartlehner G, Thaler K, Hill S, Hansen RA. How should primary care doctors select which antidepressants to administer? Curr Psychiatry Rep 2012; 14:360.
4.Lexicomp Online. Copyright © 1978-2022 Lexicomp, Inc. All Rights Reserved.