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The author discusses how depression can be managed through primary health care and gives tips on early referral.
Introduction
Depression is a prevalent, often chronic condition that has enormous personal, social, and financial consequences. Although technologies for treating depression have advanced notably over the past 20 years, many people continue to suffer needlessly, due in part to the lack of evidence-based treatment applied in primary care settings. Substantial public and private efforts have been devoted to encouraging individuals to seek care, improving recognition and diagnosis by primary care physicians and implementing evidence-based treatment practices. From these efforts have come new models of care as well as an awareness of the critical barriers impeding clinical, organizational, economic and policy implementation of effective care strategies.1
To aid family practitioners and psychiatrists, Agency for Health Care Policy and Research (AHCPR) have issued clinical practice guidelines titled "Depression in Primary Care: Detection, Diagnosis and Treatment". Key points of these recommendations are:
Evaluation
- Screen all patients with the two-questions depression screen recommended by the US Preventive Services Task Force.
- "Over the past two weeks, have you felt down, depressed, irritable or hopeless?"
- "Over the past two weeks, have you felt little interest or pleasure in doing things?”
- Perform a mental health evaluation.
Diagnosis
- Accurately establish a diagnosis (please refer to DSM-IV-TR)
- Major Depressive Disorder
- Bipolar Disorder
- Dysthymia
- Adjustment Disorder with Depressed Mood
- Determine the severity of symptoms
- Evaluate the risk of suicide or harm
- Determine family history of psychiatric illness
- Determine past history of illness and response to treatment
- Determine presence of co-morbid physical or mental illnesses
- Determine functional impairment
Treatment
- Discuss treatment alternatives, benefits and risks, with the patient and family
- Determine and implement a treatment plan
- Medication with Patient Management
- Psychotherapy
- Integrated Psychotherapy / Medication Management
- Split Psychotherapy / Medication
- Consultation (psychiatrist or mental health professional)
- Secure support services
- Referral for inpatient or intermediate care
Follow-up and Re-evaluation
- Communicate treatment plan to PCP/psychotherapist/psychiatrist
- Continue treatment plan (including medication if it has been prescribed) for 12 weeks. See the patient at least three times to assess progress, reevaluate the risk of harm and the presence of co-morbid conditions
- Communicate treatment status to PCP/psychotherapist/psychiatrist
- If not substantially recovered at 12 weeks and not on medication managed by a psychiatrist, consider a psychiatric referral
- Monitor patient for relapse for an additional twelve weeks continuing antidepressant medication
- Educate the patient and family on the risk recurrence and establish a recurrence prevention plan
- Document all evaluation and treatment visits with the patient and family in the medical record
These recommendations may be incorporated in the family practice on an appropriate basis.
Finally, it is of utmost importance for a Family Physician to recognise early signs of suicide in a patient suffering from depression. These are suicidal ideations or any frank attempt. In this situation, the Family Physician plays the crucial role of early referral to the professional or an institution capable of handling the situation.
References
- Pincus HA, Hough L, Houtsinger JK, Rollman BL, Frank RG, Emerging models of depression care: multi-level ('6 p') strategies. Int J Methods Psychiatr Res. 2003:12(1); 54-63.
- Clinical Practice Guideline For Primary Care Practitioners. Depression In Primary Care: Detection, Diagnosis And Treatment. AHCPR.
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