7 Management of Depression - Initial Decisions

7.1 Framework for Initial Decisions in the Management of Depressed Patients

Our initial plan of management is dependent on our assessment of the severity of the patients illness and the risk to the patient with suicidal thoughts. The extent of the patient's family and social support may be another important consideration. Each of us needs to be aware of our local psychiatric services and the means of access, and to use them appropriately for each patient.

Assessment of any possible aetiological features is important, but note that in a patient who is severely depressed, everything may be of concern, and ruminations which take up the whole of the days' thoughts may have no part in causation of the distress, difficult as it is to convince the patient of this.

If there is an underlying cause eg. conflict or marital distress, bereavement, loss of job, etc., then treatment of purely the symptoms will not be successful in the long-term. If the patients' cognitive function is impaired at the time of presentation, then working with them at a level which helps to find solutions to the cause may be extremely difficult. On the other hand, if their depressive disorder is considered mild to moderate in severity, with only some impairment in functioning, finding solutions with them will almost certainly minimize the depressive symptomatology.

Awareness of premorbid functioning is important, and gives indications as to possible recovery and completeness of recovery. Remember that if an individual was highly dysfunctional prior to developing a major depressive disorder, or has a personality disorder, then that will continue after the illness is treated.

7.2 Management Options for Depression

While the following all have a role in the treatment of depressive illness, the selection of the most appropriate management regime requires careful consideration of the patient, the nature and severity of the illness, his/her family and social situation, your own competence and confidence to manage depression and the availability of appropriate health services. Most depressive disorder can be successfully managed in a general practice setting.

Hospitalisation

Consider hospitalisation

• if there is an assessed suicide risk or the person is dangerous to others because of disturbed thinking eg.psychosis in depression. (Mental Health Act Regulation may be necessary in some situations. Obtain a copy of this and relevant Mental Health Forms.)
• if patient is severely agitated, or distressed.
• if patient is severely psychomotor retarded and unable to care for themselves.
• if there is significant medical care required e g intercurrent illness or dehydration

Specialist Referral

Consider specialist referral

• if further assessment is necessary or
• if the diagnosis is not clear eg . if schizophrenia or other illness a possibility (O.C.D. or Bipolar Disorder)

Antidepressant Medication

Consider antidepressant medication as the first line of treatment:-

• if the patient experiences severe and/or prolonged mood disturbance
• if neurovegetative symptoms are present
• if episodes are recurrent
• if medication has been effective in the past
• if the patient has a positive family history of mood disorder(either depressive or bipolar)
• if, as mentioned in next section, supportive psychotherapy (the talking therapies) are not effective.

 

See also: Rational Use of Antidepressant Drugs.

Psychotherapy

Psychotherapeutic intervention may target specific symptoms of the disorder, or deal with the current psychosocial problems that may be causative in the depression.

Cognitive and Behavioural Therapies target depressive symptoms and help patients to identify and correct any negative thoughts or underlying unhelpful belief systems and assumptions. This form of psychotherapy minimizes the relapse rate of depressive symptoms if skills in identifying unhelpful patterns of functioning are obtained. Behaviours which have become unhealthy in that they maintain depressive symptoms are replaced with others which promote problem solving, social skills, training, and goal setting.

Interpersonal Psychotherapies aim at resolving interpersonal or intra personal conflicts which again may maintain the depression. Various useful psychotherapeutic models are available, ranging from analytical to solution-focused and brief therapy. Consultation with a specialist is often advisable.

ECT

ECT is still a very effective treatment for severe depressive episodes especially if there are multiple physiological symptoms and signs and /or if psychosis is present. Specialist referral is essential.

Combinations of Therapies

Combination treatments involving antidepressant medication and a form of psychotherapy are often necessary in treating the depressed patient. Inpatient or outpatient treatment programmes may also be necessary. Lithium augmentation of the antidepressant can sometimes be a useful strategy, but consultation with a psychiatrist before proceeding is recommended.

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