9 On-going Management of Depression

9.1 The Natural History of Depression

It is of considerable importance to understand the course of depressive disorders and to recognize that these disorders are chronic and relapsing in a large percentage of cases.

Approximately 50% of patients with a Major Depressive Disorder, of single episode, can be expected to have a further episode. Individuals who have experienced 2 episodes have an approximately 70% recurrence rate, and with a third episode this rate increases to approximately 90%.

Two-thirds of patients recover completely, but in the other third, only partial remission or no recovery is seen. If only partial recovery occurs there is greater likelihood of developing further episodes with the same partial recovery between episodes.

DSM IV considers an Episode of Major Depression to have ended when the full criteria have not been met for at least 2 consecutive months .i.e. there is either full or partial remission. Following this, relapse is most common in the first 4 to 6 Months, but as discussed above may occur with certain precipitants. Possible courses of depressive illness are illustrated in the diagram below.

Response, remission, recovery, relapse, recurrence.ref 16

9.2 Aims of Long-term Care of the Depressed Patient

Our aim in treating the person who presents to a General Practice Clinic needs to be clear - to attain and maintain the healthiest function for this person that is possible (given that we are not miracle workers, most of the time).

For a person with a Depressive Disorder, we must constantly be aware of their need to understand the disorder, to be supported in the acute phases, to be followed closely in case of relapse, to be aware of the effects on family and economic functioning, and to be aware of potential danger times for them. For patients with a history of Major Depressive Episode, future events of significance in their life may precipitate a further episode. eg. life change, job loss, loss of spouse, divorce, displacement with job. Major illness may also precipitate a further episode.

9.3 Management of Antidepressant Medication

When assessment of the longitudinal history of the persons' symptoms reveals partial remission, evidence of Dysthymic Disorder or a severe first episode, DSM IV suggests that these persons may require more persistent treatment. Additional acute-phase treatment and longer periods of treatment may be required to attain and maintain a longer-lasting euthymia (normal stable mood) without the existence of some symptoms given in the criteria for Major Depressive Disorder.

Long term maintenance therapy with antidepressant medication is usually recommended for those persons who have experienced 3 or more episodes of major depression, or those with a clear family history of depressive or bipolar disorder, and 2 episodes of major depressive symptoms. See also 8.3 How to Use an Antidepressant

9.4 Role of Other Members of the Health Team

Involvement of health care centre staff especially at Mental Health Clinics is often required if there are any risk factors such as isolation, unemployment, parenting concerns, family factors, or chronic illness.

If depression arises in a person with significant anxiety, learning relaxation techniques with a trained relaxation therapist or physiotherapist is very useful.

A good working relationship with a number of mental health staff is of inestimable value in facilitating care of our patients with depressive disorders. Get to know a couple of psychiatrists professionally, with whom you can be in contact as necessary to discuss more difficult situations. Understand the internal workings of the local public hospital system and the staff there for when acute situations arise, and use the local Mental Health Teams regularly for help with follow-up and treatment when required.

9.5 Working with the Family of the Depressed Patient

During the ongoing care of the patient, the role of education (both of the patient and family) is important and appropriate. Resources are available to most of us from Community Health and Psychiatric Clinics, also in videos for family education, and brochures. If CBT strategies are indicated and employed in the prevention of relapse, then involvement of the spouses or supporters is very helpful. This is available through many of the inpatient units caring for depressed patients. Awareness by the spouse or supporters of the early indicators of recurrence of depressed mood can be vital to preventing full relapse.

9.6 Early Intervention Strategies

These strategies involve the patient, carer and clinician in a team management which more effectively reduces the morbidity and sequelae of chronic or untreated depressive symptomatology.
Patients, their families and their carers should be made aware of the need to recognise and act on the early signs of relapse or recurrence. It is a good idea to develop a contract with patients and document it in much the same way that we now do for, say, asthma.

Patients should be involved in the development of the contract as much as possible. Support from family will be important in carrying out the plan. The GPs role is one of educating and supporting both patient and family.

Plans might include some or all of the following:-

• documentation of maintenance plan including medication, lifestyle and behavioural strategies, frequency of appointment for follow-up
• documentation of the early warning signs of depression relapsing or recurring, individualised for the patient
• statements on the actions that the patient and family should take in such circumstances, including behavioral approaches, medication changes and contacting members of the health team

An example of a plan appears below:

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