Depression: Challenges in primary care
Published in MedicineWise News
Date published: About this date
- Assess the severity of depressive symptoms to inform treatment decisions
- Consider non-drug treatments first in minor or mild depression and alongside
antidepressants in more severe depression
- Consider an antidepressant for moderate-to-severe major depressive disorder
- Assess the specific risks of antidepressants in older people (> 65 years) including
co-morbidities, drug interactions and reduced clearance
- Advise patients what to expect from antidepressant treatment
Establish the diagnosis of depression
Depressive symptoms must be pervasive and persist for at least 2 weeks to meet the threshold for a diagnosis of major depressive disorder (MDD). The DSM-IV criteria are listed in Box 1.1 Most patients with depression or anxiety who see a GP also report somatic symptoms—often these are the presenting complaint rather than mood disturbance.2
Exclude bipolar disorder
Exclude bipolar disorder by asking about previous manic or hypomanic episodes. Consider consulting a psychiatrist if bipolar disorder is suspected; people with bipolar disorder should not be prescribed an antidepressant alone.3
Assess comorbidities and psychiatric history
Consider stressors, bereavement, personal and family history of depression, previous treatment, and psychological and physical comorbidity as part of a targeted assessment. These factors shape the management approach.4,5 A diagnosis will often require multiple consultations rather than a one-off assessment.6
Symptoms that persist for months or years require special attention, as they may be of low intensity but still cause significant impairment, and often require a combination of an antidepressant and psychotherapy.4 Dysthymia describes symptoms equal in severity to minor depression, but that persist for two years or longer.1
Box 1: DSM-IV criteria for diagnosis of major depressive disorder and minor depression1
|Clinically significant distress or impairment in social, occupational or other important areas of functioning|
|MAJOR DEPRESSIVE DISORDER|
Symptom 1 or 2 must be present, with a total of at least 5 symptoms from the list.
Present most days for past 2 weeks or more.
Symptom 1 or 2 must be present, with a total of 2–4 symptoms from the list.
Always ask directly about suicidal ideation and intent
Assess the risk of suicidal behaviour, considering previous attempts, the degree of hopelessness, evidence of planning and access to means. Seek urgent psychiatric assessment and treatment for people with significant suicide risk. People with MDD reporting suicidal ideation must be monitored closely.3-5
Make a global assessment of severity
Judge the severity of MDD by the degree of functional impairment as well as the number and intensity of symptoms. For example, people with moderate-to-severe MDD experience apathy, social withdrawal and work impairment (poor self-care may be evident), while those with mild MDD experience minimal functional impairment.1,4 A rating scale (e.g. the Kessler K-10 scale8) may help in making a global assessment.4
Use non-drug treatments first in mild MDD
In minor depression or mild MDD, close monitoring or non-drug treatments are first line, rather than an antidepressant.3,5 Consider an antidepressant if the response to non-drug treatment is unsatisfactory.B,5 At the other extreme, if psychotic symptoms are present, if the diagnosis is uncertain despite significant distress or impairment, or if symptoms are severe, consider psychiatric advice or referral (including the GP Psych Support service for non-urgent psychiatric opinion call 1 800 200 588).3B. Selective serotonin reuptake inhibitor and serotonin and noradrenaline reuptake inhibitor antidepressants are not PBS listed for minor depression or dysthymia.
Choose an SSRI initially
When selecting first-line antidepressant treatment, a selective serotonin reuptake inhibitor (SSRI) is preferred because the balance of benefits and harms is most favourable.5 On average, the differences between SSRI and other antidepressants in efficacy and adverse effects are small.9 Patient preference, experience with antidepressants, potential drug interactions and likelihood of adverse effects may influence the choice.
Venlafaxine has similar effectiveness to the SSRIs. It is less well tolerated and more toxic in overdose, and the small efficacy advantage found in trials is unlikely to be clinically significant; about 20 people need to be treated with venlafaxine rather than an SSRI for one additional person to respond.5,9 The newest drugs are not demonstrably better than SSRIs and venlafaxine9 (see NPS RADARs on desvenlafaxine [Pristiq] and duloxetine [Cymbalta]).
Allow up to 4 weeks for response
Evaluate adherence if there is inadequate improvement in 4 weeks. Then consider increasing the dose of the antidepressant within the recommended range, or switching to another antidepressant (e.g. if adverse effects are troublesome or the patient prefers to do so). When switching from an SSRI, initial options include a different SSRI, mirtazapine or venlafaxine.3,5
Continue treatment after remission
Continue antidepressant treatment for 6–12 months after remission of symptoms. People at high risk of recurrence require longer treatment and should continue for at least 2–3 years.3,5
Risk factors for recurrent depression include:
- residual depressive symptoms
- a history of 3 or more prior episodes or 2 or more episodes in the last 5 years
- a history of severe depression (especially with psychotic symptoms or a serious suicide attempt).3,5
Psychological treatments provided after recovery, such as CBT or mindfulness therapy, also reduce the risk of relapse and recurrence, and should be considered for people who have had multiple episodes of MDD.3,5,10 Over an average of about 3 years of follow up, relapse rates were 40% among people who received a course of CBT after remission, versus 73% for those who did not.11
Taper to avoid discontinuation symptoms3,5
There is no good evidence to guide tapering, but abrupt discontinuation appears to cause greater symptoms.12 Recent Australian guidance recommends at least one week between each reduction in dose and reducing the dose by no more than half each time.C 13 Reassure patients that flu-like symptoms, insomnia, nausea, sensory disturbances and other discontinuation symptoms are usually mild and last 1–2 weeks.12C. Consult the AMH for advice about discontinuing monoamine oxidase inhibitor or tricyclic antidepressants. Tapering may not be required when discontinuing fluoxetine, as it has a long half-life.13
Discuss patient preferences concerning antidepressant and non-drug treatments.3,5 Consider referring for psychological therapy via Better Access or Access to Allied Psychological Services (ATAPS) as part of a GP mental health treatment plan. There is evidence of additional benefit when an antidepressant is combined with a non-drug treatment, for example cognitive–behavioural therapy (CBT).5,14 See Table 1 for recommended non-drug treatment options.
|Close monitoring and further assessment|
Arrange a further assessment, e.g. within 2 weeks. Close monitoring by a GP (e.g. weekly contact) may improve outcomes.|
Make contact if the person does not attend follow-up appointments.5
|Education and information about depression|
|Promotes adherence to treatments. See Advise patients what to expect from antidepressant treatment.|
|Supportive counselling (empathic, active listening, allowing patient to air problems)|
There is weak evidence for short-term benefits from non-directive professional counselling.15
A GP's routine counselling is an important aspect of the therapeutic relationship.
Guided self-help based on CBT principles
Some evidence for reducing symptoms in the short term and at 12 months after completion.5,16
Recommended intensity is 6–8 sessions over 9–12 weeks, with face-to-face or telephone follow-up.5
A list of recommended books is available on the NPS website at nps.org.au/depression_books
Limited evidence, especially in MDD.18
Relaxation therapy involves progressive muscle relaxation exercises.
Activity scheduling involves identifying activities the person usually enjoys (e.g. social or recreational activities) or that give a sense of achievement, and encouraging them to set a time to do these.Sleep hygiene involves establishing good sleep habits.4
Brief psychotherapy eg, cognitive-behavioural therapy (CBT), interpersonal therapy (IPT) or problem-solving therapy (up to 6 sessions)
Has greater efficacy than usual GP care.18
If people are slow to respond or engage with therapist, more sessions may be needed.
Skills can also be learnt by GPs (i.e. Focused Psychological Strategies).
Likely to help with symptoms and may be a positive lifestyle change.5,19
* Emphasise pleasurable aspects; choose exercise the patient enjoys.
* Consider a structured, supervised group exercise program 3 times per week.* Anticipate barriers like fatigue and lack of motivation.
* Be realistic about expectations — some patients may feel guilty if unable to comply.5,20
|Computer-based CBT via a website|
Regular contact with clinicians to monitor progress may aid adherence.23
The Australian National University's Moodgym (free, originally designed for young people)
St Vincent's Hospital, Sydney, CRUfAD clinic (small fee, GP referral needed)
UK-based Beating the Blues (one-off fee)
|CBT or IPT for up to 16-20 weeks|
CBT is effective for adolescents and older people (> 65 years).26,27
Patients must be willing to engage actively with therapy. Therapy can be stopped when remission is achieved.5
Adding psychotherapy to antidepressants leads to higher response rates and is recommended in moderate-to-severe MDD.5,14
Functioning may first need to improve before patients can engage in psychological therapy.Benefits of CBT persist with reduced relapse rates after treatment.11
Detailed explanations promote adherence to treatments. Important points are listed in Box 2. Back up verbal counselling with printed information or online resources.
Also see our NPS depression knowledge hub for links.
Box 2: What to tell patients when prescribing an antidepressant
- Some side effects are likely (e.g. nausea), but most will go away after 1–2 weeks. If you are concerned about the side effects you are experiencing, talk to your doctor rather than stopping treatment. It may be possible to reduce side effects or to find another medicine that suits you better.
- You may feel more anxious or agitated at first. If you are concerned about this, or if your mood gets worse or you have thoughts about suicide, talk to your doctor as soon as you can.
- You will not feel better immediately. It can take up to 4–6 weeks to feel the full effect, so don't give up too soon. Most people start to feel better within 1–2 weeks.
- You may have to try more than one treatment to find one that works for you.
- Don't stop taking antidepressants as soon as you start to feel better. You will need to take antidepressants for at least 6 months. Studies suggest that people who stop treatment too early are more likely to relapse.
- Antidepressants are not addictive. Even so, don't stop taking them abruptly, because it can cause unpleasant side effects. Talk to your GP and pharmacist about how to reduce the dose gradually. Some medicines (including herbal and natural medicines) are not safe to take with your antidepressant; for example, St John's wort and many cough and cold medicines. Tell your doctor and pharmacist about all medicines you take.
Assess the specific risks of antidepressants in older people
Antidepressants are effective for MDD in people aged ≥ 55 years.28 There is little evidence that antidepressants are effective for depressive or behavioural symptoms (e.g. agitation) secondary to dementia.29.30
Consider non-drug treatments
As for other patients, consider non-drug treatments for older people as they are effective but underused in this population.31 For example, there is good evidence for psychological therapies such as CBT in people with depression aged ≥ 60 years.27 For minor depression or mild MDD, especially when related to circumstances such as bereavement or social isolation, options include grief counselling and 'social prescribing' (e.g. referral for group activities).4
Start low, go slow
When an antidepressant is prescribed, a low starting dose and slow titration reduce adverse effects.3 Maintenance and maximum doses may be lower than for younger people; age-related reductions in drug clearance have been identified for some antidepressants.32 For example, recommended maximum doses are citalopram 20 mg daily or escitalopram 10 mg daily, for people aged ≥ 65 years.33,34
A/Prof Grant Blashki, Nossal Institute for Global Health & Melbourne Sustainable Society Institute, University of Melbourne
Dr David King, Discipline of General Practice, School of Medicine, The University of Queensland
Prof David Clarke, School of Psychology and Psychiatry, Monash University
Any correspondence regarding content should be directed to NPS. Declarations of conflicts of interest have been sought from all reviewers.
- Diagnostic and statistical manual of mental disorders. 4th, text revision ed. Washington DC: American Psychiatric Association, 2000.
- Clarke DM, Piterman L, Byrne CJ, et al. Somatic symptoms, hypochondriasis and psychological distress: a study of somatisation in Australian general practice. Med J Aust 2008;189:560–4.
- Therapeutic Guidelines: Psychotropic. 6th ed, 2008.
- beyondblue. beyondblue guide to the management of depression in primary care. 2010. (accessed 30 January 2012).
- National Institute for Health and Clinical Excellence. Depression. The treatment and management of depression in adults (updated edition) National clinical practice guideline 90. 2009. (accessed 2 January 2011).
- Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 2009;374:609–19.
- Gunn JM, Gilchrist GP, Chondros P, et al. Who is identified when screening for depression is undertaken in general practice? Baseline findings from the diagnosis, management and outcomes of depression in primary care (DIAMOND) longitudinal study. Med J Aust 2008;188:S119–25.
- Slade T, Grove R, Burgess P. Kessler Psychological Distress Scale: normative data from the 2007 Australian National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry 2011;45:308–16.
- Gartlehner G, Hansen RA, Morgan LC, et al. Comparative benefits and harms of second-generation antidepressants for treating major depressive disorder: An updated meta-analysis. Ann Intern Med 2011;155:772–85.
- Piet J, Hougaard E. The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: a systematic review and meta-analysis. Clinical psychology review 2011;31:1032–40.
- Vittengl JR, Clark LA, Dunn TW, et al. Reducing relapse and recurrence in unipolar depression: a comparative meta-analysis of cognitive-behavioral therapy's effects. J Consult Clin Psychol 2007;75:475–88.
- Warner CH, Bobo W, Warner C, et al. Antidepressant discontinuation syndrome. Am Fam Physician 2006;74:449–56.
- Australian Medicines Handbook, 2012.
- Cuijpers P, Dekker J, Hollon SD, et al. Adding psychotherapy to pharmacotherapy in the treatment of depressive disorders in adults: a meta-analysis. J Clin Psychiatry 2009;70:1219–29.
- Bower P, Knowles S, Coventry PA, et al. Counselling for mental health and psychosocial problems in primary care. Cochrane Database Syst Rev 2011;9:CD001025.
- Anderson L, Lewis G, Araya R, et al. Self-help books for depression: how can practitioners and patients make the right choice? Br J Gen Pract 2005;55:387–92.
- Morgan AJ, Jorm AF. Self-help interventions for depressive disorders and depressive symptoms: a systematic review. Ann Gen Psychiatry 2008;7:13.
- Bortolotti B, Menchetti M, Bellini F, et al. Psychological interventions for major depression in primary care: a meta-analytic review of randomized controlled trials. Gen Hosp Psychiatry 2008;30:293–302.
- Mead GE, Morley W, Campbell P, et al. Exercise for depression. Cochrane Database Syst Rev 2009:CD004366.
- Institute for Clinical Systems Improvement. Health care guideline: major depression in adults in primary care. 14th ed, May 2011. (accessed 20 January 2012).
- Foroushani PS, Schneider J, Assareh N. Meta-review of the effectiveness of computerised CBT in treating depression. BMC Psychiatry 2011;11:131.
- Mackinnon A, Griffiths KM, Christensen H. Comparative randomised trial of online cognitive-behavioural therapy and an information website for depression: 12-month outcomes. Br J Psychiatry 2008;192:130–4.
- Christensen H, Griffiths KM, Korten AE, et al. A comparison of changes in anxiety and depression symptoms of spontaneous users and trial participants of a cognitive behavior therapy website. J Med Internet Res 2004;6:e46.
- Cuijpers P, Geraedts AS, van Oppen P, et al. Interpersonal psychotherapy for depression: a meta-analysis. Am J Psychiatry 2011;168:581–92.
- Spielmans GI, Berman MI, Usitalo AN. Psychotherapy versus second-generation antidepressants in the treatment of depression: a meta-analysis. J Nerv Ment Dis 2011;199:142–9.
- Klein JB, Jacobs RH, Reinecke MA. Cognitive-behavioral therapy for adolescent depression: a meta-analytic investigation of changes in effect-size estimates. J Am Acad Child Adolesc Psychiatry 2007;46:1403–13.
- Pinquart M, Duberstein PR, Lyness JM. Effects of psychotherapy and other behavioral interventions on clinically depressed older adults: a meta-analysis. Aging Ment Health 2007;11:645–57.
- Tedeschini E, Levkovitz Y, Iovieno N, et al. Efficacy of antidepressants for late-life depression: a meta-analysis and meta-regression of placebo-controlled randomized trials. J Clin Psychiatry 2011;72:1660-8.
- Nelson JC, Devanand DP. A systematic review and meta-analysis of placebo-controlled antidepressant studies in people with depression and dementia. J Am Geriatr Soc 2011;59:577–85.
- Seitz DP, Adunuri N, Gill SS, et al. Antidepressants for agitation and psychosis in dementia. Cochrane Database Syst Rev 2011:CD008191.
- George K, Davison TE, McCabe M, et al. Treatment of depression in low-level residential care facilities for the elderly. Int Psychogeriatr 2007;19:1153–60.
- Boyce RD, Handler SM, Karp JF, et al. Age-related changes in antidepressant pharmacokinetics and potential drug-drug interactions: a comparison of evidence-based literature and package insert information. Am J Geriatr Pharmacother 2012;10:139–50.
- Therapeutic Goods Administration. Citalopram and heart problems - changes to recommended doses. Safety advisory. 4 November 2011. (accessed 23 February 2012).
- Lundbeck Australia Pty Ltd. Lexapro product information. 19 May 2011
- Coupland C, Dhiman P, Morriss R, et al. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ 2011;343:d4551.
- de Abajo FJ. Effects of selective serotonin reuptake inhibitors on platelet function: mechanisms, clinical outcomes and implications for use in elderly patients. Drugs Aging 2011;28:345–67.
- Jacob S, Spinler SA. Hyponatremia associated with selective serotonin-reuptake inhibitors in older adults. Annals Pharmacotherap 2006;40:1618–22.
- Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Int Med 2009;169:1952–60.
- Banerjee S, Hellier J, Dewey M, et al. Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. Lancet 2011;378:403–11.