Introduction: clinical issues in depression for the family physician

Journal of Family Practice, Dec, 2003

Primary care has been called the "de facto mental health system in our country. (1) Because of sociocultural and economic pressures ranging from the perceived "stigma" of mental illness to the restrictive reimbursement for psychiatric care, patients often turn first to their family physicians for the evaluation and treatment of psychiatric illness. Particularly in the realm of depressive illnesses, family physicians frequently find themselves on the forefront of mental health care. Statistics confirm that major depression, dysthymia (chronic low-grade depression), and minor depressive episodes (less severe episodic illnesses) may affect as many as 30% of primary care patients, (2,3) and that family physicians currently prescribe 80% of the antidepressants used in the United States. (4) Clearly, the realities of our present healthcare climate demand that family physicians be prepared to recognize and treat depression. However, whether as a result of time limitations, economic factors, or knowledge-based constraints, at least 2 observational studies have reported that family physicians correctly diagnose less than 50% of patients with depressive disorders, and that only 25% of patients with depression are effectively treated when managed in the primary care setting. (5,6)

* Scope of the problem: Physical symptoms and depression serves as a brief introduction to the prevalence and collateral impact of depression in the primary care setting.

* It is followed by A 4-step program for the diagnosis and management of depression, which presents strategies for effective screening of and assessment for depression in primary care.

* Depression and comorbid medical illness: Therapeutic and diagnostic challenges focuses on important clinical factors in treating the patient with newly diagnosed depression.

* Medications and their mechanisms of action are addressed in Applying neuropharmacology when treating patients with depression, which discusses the efficacy and side effects of the newer-generation antidepressant therapies. It also puts this information into perspective to help clinicians select the most appropriate agent for the individual patient based on side-effect profile.

* From paper to patient: How do you translate science into clinical practice? illustrates the usefulness of patient profiling in the selection of pharmacotherapy and anticipated side effects. Although each patient is unique, patient profiling can serve as a valuable tool in anticipating patient needs and surveillance for adverse side effects.

* Treatment regimens for managing depression in the family practice and Response to treatment: gaining and maintaining remission present best-practice suggestions and options.

* Finally, the strategies from each section are applied and reinforced in a practical conceptualization in the Putting theory into practice: A challenging case study.

ABOUT THIS PUBLICATION

This supplement has been constructed to provide very practical and scientifically relevant strategies for the diagnosis and management of depression in the primary care setting. Its approach was developed in full accordance with current American Psychiatric Association (APA) guidelines for the management of depression, which state that "antidepressant medications have been shown to be effective. The effectiveness of antidepressant medications is generally comparable between classes and within classes of medications. Therefore, the initial selection of an antidepressant medication will largely be based on the anticipated side effects, the safety or tolerability of these side effects for individual patients, patient preference, quantity and quality of clinical trial data regarding the medication, and its cost. (7)

To provide current and relevant information throughout this article, evidence-based material from key studies in the literature has occasionally been supplemented with helpful, clearly identified, anecdotal information.

Each section of this supplement contains strategies to increase clinicians' awareness and management expertise. Where appropriate, additional warnings and useful clinical anchors have been clearly labeled as "Red flags" and "Pearls," respectively. The treatment-oriented decision-making processes presented include strategies to:

* Stratify treatment decision making by patient type

* Distinguish between and organize antidepressants by their neuropharmacological characteristics, properties, and side effects

* Consider the complexity of conditions critical to initiating medication in a newly diagnosed depressed patient

In an effort to provide optimal medical and psychiatric care, the framework of this discussion also includes consideration of the patient's culture, values, and lifestyle--significant factors which may positively or negatively influence treatment choices. The importance of patients' perceptions and beliefs in adherence to treatment, and the positive relation to outcome, have been documented through several decades of psychological and medical research. (8-11) It also reviews adverse side effects and patient perceptions of therapeutic success. (7)