The active management of depression - Clinical Update

Journal of Family Practice, Sept, 2002 by Larry Culpepper

Education

Education should help patients understand and accept the diagnosis, reduce any stigma they or their families might attach to major depression, and build increased adherence to subsequent treatment. (26) It might be helpful to provide a brief explanation of the biologic basis of depression (including biochemical changes in brain function and "chemical imbalances" of serotonin and other neurotransmitters). Explaining pharmacotherapeutic effects (if medication is desired) as mechanisms to help rebalance brain chemistry further emphasizes the biologic basis of depression and decreases any perceptions that depression is a result of moral or character weakness. This educational message should also stress that antidepressants are not habit-forming or addictive, are not "uppers" or "downers," and are not tranquilizers. The physician also should convey a positive prognosis but note that several weeks and, possibly, adjustments in treatments, may be required. For patients choosing antidepressants, the McArthur Foundation Initiative has identified 7 key educational messages (Table 2). (27)

Counseling

Patients often benefit from counseling regarding sleep, exercise, and substance use. Many patients with depression experience early morning awakening. Those with agitated depression also often experience delayed sleep onset associated with worry. Providing the patient with information on basic sleep hygiene, exercise, and encouraging abstinence from or moderation in consumption of alcohol might all help. (28-30) Additionally, sleep disturbances can indicate the possibility of comorbid disorders. A report that a patient fears going to sleep because of nightmares suggests posttraumatic stress disorder.

For some patients, counseling by the family physician or through referral may be a helpful treatment adjunct. Often depressed patients have deficient coping mechanisms and need assistance in developing strategies to resolve issues in their lives. Principles used in cognitive behavioral therapy might be helpful in patient education and counseling. (31) These include problem-solving strategies to resolve stressful concerns and cognitive techniques to identify and correct distorted or maladaptive thought patterns. (29)

As patients respond to depression treatment, an additional component of primary-care-based counseling should target reinvolvement with pleasurable social and physical activities. This may simply involve identifying activities the patient enjoyed prior to the onset of depression but has since stopped, and focusing on the steps required to reactivate these interests.

Shared decision-making with regard to treatment will improve subsequent patient adherence. (27) Treatment options include psychotherapy, particularly cognitive behavioral therapy, pharmacotherapy, and electroconvulsive therapy. The latter should be considered for severely depressed patients, particularly persons with few social supports who are at significant risk of suicide. (25)

Cognitive behavioral therapy and other psychotherapies can show effectiveness equal to that of pharmacotherapy, although response usually lags by a month to 6 weeks compared with that attained by pharmacotherapy. (32) For moderately to severely depressed patients, pharmacotherapy is the treatment of choice in part because of its more rapid onset of action. (25)