MANAGEMENT OF DEPRESSION FOR GPs
Here is a brief overview of the diagnosis and treatment of depression.
Diagnosis in general practice:
Depression normally manifests itself as unusual tiredness , multiple physical symptoms, or “not coping”. Other early signs of depression include making fewer social contacts with other people, such as through SMS, and in particular having unusual problems remembering what they read or following a TV program.
Differential diagnosis:
Thyroid function tests, full blood count and blood sugar estimates are appropriate. Hypothyroidism makes patients appear depressed or cognitively impaired.
Overall management:
Patients need to understand they have a stress-induced change in their thinking patterns and in their biochemistry. They particularly want some discussion and counselling, where they can talk about their problems. CBT is useful, and referral to a psychologist or a psychiatrist may achieve this, or the patient may be referred to Moodgym (which they can Google), a free online CBT service provided by the Australian National University in Canberra. For anything more than mild symptoms, patients should also be given antidepressants, with the explanation that their biochemistry is damaged by the stress they are experiencing. Research repeatedly shows that the combination of therapy plus medication is far better than either approach alone.
Choice of antidepressants:
Cymbalta, Efexor, Pristiq and Avanza are dual-acting antidepressants, operating on both the serotonin and noradrenaline system. SSRIs (Lexapro, Zoloft, Aropax, Prozac, etc.) operate on the serotonin pathway. Aurorix is a weak antidepressant with very few side-effects. Edronax operates on the noradrenalin system. However, there is no way of predicting which antidepressant will work for which person, and any antidepressant has roughly a 50% chance of being an effective long-term antidepressant for that person. Therefore, if one antidepressant does not work, do not be afraid to change it, and in fact it is important to keep on experimenting with antidepressants until success is achieved in the form of total abolition of the patient’s symptoms, as evidenced by the patient being able to concentrate and remember normally.
Overall use of antidepressants:
It is strongly advised that you start with a low dose for the first few days (such as half a tablet) to stop the agitation which a significant minority of patients will develop when starting an antidepressant, especially in full dose. At 2-3 weeks, decide if the patient is markedly improved, in which case you are on the right track. If the patient is moderately improved at this stage, increase the dose! (There is nothing specific about the average dose of an individual antidepressant tablet). If there is no response at three weeks, it is extremely unlikely the patient would benefit from that particular antidepressant, and a change of antidepressant is indicated.
Ongoing management:
Continue to increase the antidepressant as needed, up to the manufacturer’s maximum recommended dose, or until remission is achieved, i.e. total abolition of symptoms. The patient will feel he or she is back to their normal self, and they will report that their concentration and memory are good. If further benefit is required, perhaps there is a justification to add in benzodiazepines or low dose atypical antipsychotics, which are dramatically effective in many patients with depression, as a supplement to antidepressants, or referral to a psychiatrist with a view to combination antidepressants is appropriate, or you may with to read the sections on this site about that issue.
Longer-term treatment:
You may wish to advise your patients to increase their medication if their symptoms return, such as premenstrually, when they have had a virus, or at times of stress. Equally, if patients start becoming drowsy or yawning, or have trouble finding the right word when they are thinking or speaking, or make silly mistakes (such as putting sugar in the fridge), it indicates their symptoms have been overwhelmed by the medication, and a reduction in medication is appropriate. The effects of such dose changes are usually evident within 48-72 hours of dose change.
Duration of treatment:
It is difficult to convince patients that depression is not like treating an infection, where complete or partial abolition of symptoms is usually adequate, allowing the immune system to do the rest. In reality, treatment of depression is like holding a destructive force under water long enough for it to lose strength from lack of exposure to the air. Prolonged high dose medication is the ideal to achieve this end. Reducing the duration or the dose of medication allows the destructive force to get a breath of fresh air, strengthening it for more attacks. Research suggests that patients should take antidepressants for one year after their first episode of depression, for two years after their second episode of depression, and for very many years, if not lifelong, after three or more episodes of depression, as relapse is statistically almost inevitable. Learning techniques to reduce anxiety, manage stress and perhaps learning CBT through Moodgym or appropriate reading, helps prevent relapse.
Dealing with predisposing factors:
Elsewhere on this site are sections dealing with improving relationships, stopping arguments, becoming more assertive, becoming less obsessional etc.