The active management of depression - Clinical Update

Journal of Family Practice, Sept, 2002 by Larry Culpepper

A patient who responds positively to the 2 screening questions in Table 1 or to another screening approach should be further evaluated to confirm the diagnosis of major depression. Many primary care clinicians do dais through unstructured history taking. Others use an instrument such as the previously discussed PHQ-9. This tool offers an advantage because it provides a reliable symptom assessment, measures severity, and can be repeated over time to evaluate therapeutic response. (8)

The physician should consider bereavement and substance abuse as possible causes of depression; bereaved patients who continue to meet criteria for major depression at 2 months often benefit from treatment. By that time, the sadness, poor concentration, and other symptoms associated with normal grief are no longer constant and occur in waves brought on by memories. Conversely, persons also suffering from depression report these symptoms as enduring and autonomous. (18)

The primary care physician also should inquire about agitation and symptoms of anxiety disorders. These are experienced by 85% of depressed patients; 50% have comorbid anxiety disorders. (19-21) Identification of such comorbidity is helpful in determining treatment, evaluating response, and managing patients over the long term. The Prime-MD, available in multiple languages, is also useful for screening for both anxiety and substance abuse, which can complicate both the recognition and treatment of comorbid depression. (9)

Sexual function is often affected by depression. The physician should inquire about sexual arousal, erection or lubrication, and orgasm during the initial assessment. (22) Approximately 50% of women and 40% of men with major depression report sexual-arousal problems, and 15% to 20% report orgasm problems during the month prior to diagnosis. (23) Further questioning can assess whether this dysfunction is caused by another disorder (eg, diabetes) or whether it is part of the depressive syndrome. This provides a baseline for later assessment of side effects and treatment effectiveness, and it communicates to the patient that the physician will be attentive to rids area. In discussing sexual function with depressed patients, it may be helpful to tell patients that a study of the effectiveness of treatment of depression with selective serotonin reuptake inhibitors (SSRIs) found that patients reported modestly improved sexual function with treatment. (24)

Management of Major Depression

The acute management of the patient with major depression includes patient education, shared decision-making regarding a treatment modality, supportive counseling, and treatment-specific counseling. (25) Education and counseling should extend over the initial weeks of treatment and be combined with monitoring response, identifying and managing any treatment-emergent side effects, and adjusting medications. Long-term management goals include attaining full remission of symptoms, assisting the patient to return to full functional status, integrating depression care with the treatment of other chronic illnesses, maintaining or tapering pharmacologic treatment, and monitoring for and preventing relapse or recurrence.