Well worth a read
Well worth a read
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Orla Foley
A Guide to Treating Depressionhttp://www.medscape.com/viewarticle/835809IntroductionWhen a patient is referred to a psychiatrist's office for the first time, they often do not know what to expect. Am I going to ask them to lie down on my couch? Are we going to talk about their childhood, their parents, or their nightly dreams? This unknown can keep patients suffering from depression from seeking help.In this article, I will lay out how I evaluate and develop a treatment plan for a patient with depression who presents to my outpatient psychiatry clinic. I hope this article can lift the veil on what an initial evaluation with a psychiatrist entails. As a primary care physician, what follows can help you to better assist patients with depression in your office and also to help you understand the important role a psychiatrist can play in evaluating and treating a patient suffering from depression.The Initial Psychiatric EvaluationIf your patient has never been to a psychiatrist, it may surprise them to find that the first visit in my office is very similar to what they experience in yours. One difference is that I always start off by reminding my patients that everything we discuss is confidential, unless what they discuss is dangerous to themselves or someone else.I then explain that we will use the first visit as a consultation. During this hour, we both will get to know each other. I prompt the patient to discuss what brought them to my office and what they would like to work on together.Next, I ask the patient a series of questions that help me get up to speed regarding their mental health, general health, and family history. This evaluation interview follows the standard history and physical exam format that most specialties use in their initial appointment. It may comfort your patients to be reminded that psychiatrists are medical doctors who specialize in diseases of the mind and spirit.During the initial evaluation of a patient with depression, I always seek to rule out medical causes. Depression (and also mania, anxiety, and thought disorders) can be caused by medical problems, such as thyroid disease, infections, medication side effects, hormonal abnormalities, and many other treatable medical conditions.One tool that I use to rule out medical causes of depression is laboratory testing. Some patients will present to my office with lab results. However, I usually order them during the initial visit.The most common tests that I order to rule out medical causes of depression include a complete blood count, a comprehensive metabolic panel, thyroid-stimulating hormone, thyroxine, vitamin D, and urinalysis. Other lab tests I may consider include vitamin B12, folate, testosterone (free and total), a pregnancy test, rapid plasma reagin, a urine drug screen, and fasting lipids. This is by no means an exhaustive list, but it should give you a place to start if you have a patient in your office who presents with depression.If a medical explanation exists for their symptoms, I always enlist the patient's primary care doctor or a specialist. However, if medical causes are ruled out, then I focus on the psychiatric causes and treatment of their symptoms.Formulation of the Treatment PlanWhen a patient presents with depression, there are several treatment options. As such, a thorough history needs to be collected during this initial evaluation to guide your decision-making. Every patient is unique, and it is important to discuss their history of treatment failures, treatment successes, and treatment options that have not been tried in the past. Obtaining that history, to inform your future prescribing, can help to improve outcomes.In addition, it is important to rule out such conditions as bipolar disorder, attention-deficit/hyperactivity disorder, anxiety, psychosis, and addiction. The presence of these conditions influences which medications are suitable for use in a patient who presents with depression. A proper diagnosis is imperative in order to develop an effective treatment plan.Once I collect the patient's history, I formulate a treatment plan based on the severity of the patient's symptoms, how much the depression is affecting their ability to function at work or home, and their history of response to previous treatments. If a patient has minimal symptoms and the depression is having a minimal impact on their ability to function, accordingly I take a more conservative treatment approach. However, if the patient presents with a history of several treatment failures, severe depression, and an inability to work or function at home, then it is prudent to be more aggressive and use several treatment modalities from the onset.Regardless of the severity of the patient's depression, treatment history, or current ability to function, I always support their decision to come for a consultation. Whether to seek assistance can be a very difficult decision, and one that your patient may have put off for a long time. I strongly believe that a referral to a psychiatrist can be the most important step to help for depression. Even a single consultation can help to clarify the diagnosis, rule out medical or psychiatric comorbidities, define treatment options, and begin the healing process.The Role of PsychotherapyPsychotherapy is the most common initial treatment tool that I use with my patients who suffer from depression. There are numerous evidence-based therapies for depression. The type of therapy I use is specific to what the patients discuss during their initial evaluation and subsequent follow-up visits. I base the type and intensity of therapy on my patients' stressors, symptoms, and preference for the frequency of follow-up visits.All of my patients receive supportive therapy. This is a type of therapy that you can easily incorporate into your visits with patients who are suffering from depression. At each appointment, I provide an empathic environment in which they can discuss any number of concerns and stressors in a supportive, nonjudgmental, and noncritical atmosphere. I seek to help my patients make their own connections and discover insights and solutions, while working to move forward through difficult problems and situations.Some patients may have cognitive distortions that contribute to their depression. Examples include polarized ("black and white") thinking (in which patients feel that they are either perfect or a total failure, with no middle ground) or overgeneralization (in which patients draw general conclusions from a single incident—eg, if something happens once, they expect it to happen again and again).With patients whose thought distortions are negatively affecting their mood, I use cognitive-behavioral therapy (CBT), which is designed to change these thought processes. If you identify such a patient, you can discuss CBT with them. In some cases, it can be of benefit to simply educate the patient regarding the connection between their thoughts, memories, and experiences and their feelings. In more severe cases, referral to a psychiatrist or a therapist who performs CBT is indicated.If my patients have a history of trauma, a stressful childhood, or a pattern of poor functioning in a number of similar settings throughout their life, I may use psychodynamic psychotherapy. During these sessions, I work with patients to uncover their less obvious or subconscious beliefs, feelings, and memories. These factors often influence behavior, thoughts, and emotions without our knowledge. By identifying how memories and experiences are contributing to their current patterns of thought and behavior, my patients can better understand why they feel depressed or anxious, as we work to decrease this negative influence.There are many other types of therapy I utilize, and several others to which I refer my patients in the community. Interpersonal psychotherapy can be very beneficial if relationships and social encounters are the root of stress, anxiety, and mood problems. Eye-movement desensitization and reprocessing can be very helpful for trauma and anxiety associated with depression. Dialectical behavioral therapy can be very useful in patients whose belief systems or patterns of interaction with those around them causes dysfunction of mood and behavior.There are also intensive outpatient programs for the patients who are most negatively affected by depression and whose functioning is the most severely impaired. These programs meet several times during the week and for several hours each session. I advise that if my patient's depression is severe enough to cause a leave from work or impaired ability to carry out obligations at home, it warrants this more intensive therapy.If you are the patient's general practitioner, I would not advise you to use these types of therapy unless you are trained to do so. However, now you can begin to educate your patients on how therapy is personalized to their specific needs.If you are unsure about what type of therapy your patients would most benefit from, a referral to a psychiatrist can assist with recommendations of therapy options. The psychiatrist plays an instrumental role in making a formal diagnosis and formulating the treatment plan. In many cases, I perform therapy in my office; in other cases, I may refer my patient to another psychiatrist, a psychologist, or other therapist who specializes in a specific type of therapy.The most important factor when selecting who your patient will go to for therapy is fit. They must feel that their therapist understands their concerns and provides a safe and supportive environment for healing. The second most important factor is the type of therapy used. A psychiatrist can be instrumental in helping you and your patients determine what type of therapy will provide them with the most benefit.Lifestyle Change and Behavioral ActivationDepression is associated with behavioral changes, as noted in my recent Medscape article on the signs of depression. In brief, depression tends to lead to social isolation and a decreased interest in hobbies, nutrition, exercise, and other enjoyable activities.Therefore, as difficult as it may be, I always encourage my patients with depression to take an inventory of their current behaviors. These include attention to diet/nutrition, exercise/physical activity, recreational activities/hobbies, chores/bill paying, and personal hygiene. More often than not, when patients evaluate these areas, they find that they have significant deficits compared with their predepression behavior and levels of activity.Trying to change all of these areas of behavior at once is overwhelming, frustrating, and counterproductive. Therefore, I work with my patients to develop a personalized plan that is tailored to their current motivation, functioning, and abilities. This may involve picking a single area of deficit and highlighting one goal for each day. This could include walking around the block, showering each morning, or picking a book or magazine and reading a chapter or single page. Even small victories and accomplishments can lift a patient's mood when depression has caused so much pain and struggle.The important part is successfully completing a task that is enjoyable or has been proven to improve depression. Exercise increases endorphins, raises vitamin D levels (from the sun), and can improve sleep and energy. All of these benefits are known to improve depression. Better nutrition can directly improve energy, health, and mood as well. Unfortunately, depression can keep our patients from having the motivation to do the very things that will help them to feel better.I encourage you to explore the behavioral changes that your patients with depression have experienced. It does not take long to uncover areas of deficit and provide education regarding the benefits of increasing their activity level. The most important factors to focus on are their current level of motivation, the duration of the behavioral deficits, and their baseline activity levels before the depression episode. You can then advise your patients on what changes can help their mood recover and try to point out how their current behavior and activity level have decreased from before they became depressed.Work with your patients to develop a personalized plan to activate their behavior. However, if they are uninterested or unwilling, pushing a patient to do something before they are ready can be detrimental to the therapeutic alliance and counterproductive.It is also important to recognize what behavior changes are due to the depression episode and which are not. If someone has never had a healthy diet, gotten regular exercise, been social with friends, or paid bills on time, then these behaviors are very unlikely to be due to their current depression. That is not to say that making a positive impact on these behaviors would not be helpful. On the contrary: Exercise, for example, can help anyone, regardless of their athletic prowess or history, feel better. However, when working with a patient who has never engaged in a certain behavior, it is important to "start low and go slow."Accordingly, I advise slower and smaller changes the longer my patient has been depressed. For example, if it has been a year since a once-avid gym-goer has worked out, I advise easing back into a routine more slowly than if it has only been a month or two.PsychopharmacologySome patients come to my office looking for "a pill" to help. Others come and start off by saying, "I don't believe in medication." Regardless of their preconceived beliefs about medication, I always educate my patients so that they can make a balanced decision about the risks, benefits, and alternatives to every treatment option. I work with them to decide whether a medication is right for them. It is especially important for us to be on the same page, because the patient makes the ultimate decision whether or not to take a medication after they leave my office.Several medications have been proven to be of benefit in the treatment of depression. They generally fall into a specific class of medication and include selective serotonin reuptake inhibitors, serotonin/norepinephrine reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors. Other medications that do not fit as nicely into a specific class have also been proven to be useful in the treatment of depression. When assessing which medication may be right for a patient, it is always important to consider their history of medication successes and failures.When taking a patient's medication history, it is important to ask how the medications were administered and at what doses. For example, a patient may report that a medication made them "too tired." Therefore, you should inquire about what time of day they were taking the medication, to rule out whether they were erroneously taking a potentially sedating medication in the morning. In this case, it could be worthwhile to prescribe a medication again, with the proper administration time. If you do not collect the full medication history, you may miss opportunities to utilize medications that have the potential to be very beneficial.In another example, a patient may report that a medication "never worked." You should discuss what dose the patient was previously prescribed and also the duration of treatment. You may find that the patient was taking a subtherapeutic dose or was given only a limited trial. I generally do not consider a medication trial a failure until the patient has had 6-8 weeks on a therapeutic dose without the desired effect. Prescribing a medication that a patient reports has "never worked" may turn out to be beneficial with proper dosing and adequate duration of treatment.If there are medications that a patient reports they were unable to tolerate, or that did not work well in the past (with a full trial at therapeutic dosing), I tend to avoid those. In contrast, medications that worked well in the past are more likely to help again now.After considering medication history, I then look at the patient's specific symptoms of depression. These symptoms serve as our targets for treatment and align better with some medications and worse with others. I target the most severe and urgent symptoms, and also comorbid symptoms, such as anxiety, thought distortions, obsessions, and compulsions.I work with my patients to pick a medication or combination of medications that best suits their personal and current needs. My goal is also to use the fewest number of medications and the lowest effective doses possible. Having a psychiatrist manage medication is important because medications affect each patient uniquely.At each visit, I evaluate the need to adjust the prescribed medications through changes in dosing (up or down), or augmenting them with additional medications, to achieve optimal outcomes. It is important to understand that the medications used in the treatment of depression can take a week or two to take effect. The medications often do not reach their maximum effectiveness for 6-8 weeks after initiation and subsequent dose changes. Therefore, follow-up visits should be scheduled around these factors to optimize your patient's return to health. For example, if you start an antidepressant medication without follow-up in 2-4 weeks, you will miss opportunities to make dose changes to achieve maximum efficacy with minimal adverse effects.Psychotherapy vs MedicationBecause the medications used in the treatment of depression can take up to another 6-8 weeks to have maximal effect, it is important to simultaneously utilize the other treatments options in our arsenal. This is especially true for patients with more severe depression or those who have not responded quickly to medications in the past. That is why I discuss psychotherapy, lifestyle changes, and behavioral activation first. These treatment modalities can have significant positive effects on depression immediately and can serve as a bridge until medication can take full effect.Conversely, some patients need to get started on medication and improve to a point where they can engage in therapy or change their behavior. In addition to medication, a psychiatrist can determine whether other treatments, such as electroconvulsive therapy, transcranial magnetic stimulation, or vagus nerve stimulation, are right for a patient. Every patient is unique, and the treatment plan should be consistently adjusted to his or her changing needs.ConclusionThe hardest step for the patient is often the first step: making an appointment with their primary care doctor or finding a psychiatrist. But when dealing with depression, it is always better to get help before hitting rock bottom. I hope this information helps you to better evaluate and support your patients in getting the assistance that they need.
