REVIEW ARTICLE
DEPRESSION IN PRIMARY CARE
PART 2: MANAGEMENT
XV Pereira M Psy Med,
AM Zainab M Med (Psy)
Drs Xavier Vincent Pereira and Zainab Abdul Majeed are from the Department of Psychiatry, International Medical University, Seremban, Malaysia
Conflict of interest: none
The management of depression in the primary care setting should ideally take a biological, psychological, and sociological approach. Antidepressants are the most commonly used biological agents in the treatment of depression. Psychological therapies and psychosocial interventions improve the outcome of treatment when combined with pharmacotherapy. Clinical depression is treatable and thus efforts should be made to alleviate the suffering of patients with depression.
Key words: Depression, antidepressants, psychotherapy
INTRODUCTION
Managing depression in the primary care and general practice setting is challenging.1,2 The common reasons leading to this challenge are:
- The constraints of time
- Insufficient training at the undergraduate level
- Somatisation of symptoms
The use of pharmacological agents often enables the physician to circumvent time constraints. Difficulties arise when knowledge about the properties and use of these agents is lacking.3 The other factor that often hinders the management of the depressed patient is that psychological and social issues are inadequately addressed. Psychological and social interventions should accompany pharmacological therapy in order to bring about remission of symptoms in the depressed patient.4,5
Appropriate management of depression requires knowledge of the severity and type of depressive disorders.5 Depressive disorders can be categorised as mild, moderate or severe. Severe depression can result in psychosis. A chronic mild to moderate depression lasting more than two years is termed dysthymia. Depression can also be part of bipolar disorder. There is a variation in the management of each of the above.
The National Institute of Clinical Excellence (NICE) in the UK has guidelines for the management of depression in primary and secondary care.6 These guidelines use a stepped care model which matches resources to the severity of the illness.
Mild depression can be handled in primary care and does not need pharmacological therapy. The NICE guidelines suggest watchful waiting, guided self-help, exercise and brief psychological interventions. Moderate to severe depression can also be handled in the primary care setting with medication, psychological interventions and social support. Severe depression with psychosis and risk of suicide, recurrent atypical and treatment-resistant depression should be managed by mental health specialists.
