The main aims of treatment are to improve mood and quality of life, reduce the risk of medical complications, improve compliance with and outcome of physical treatment, and facilitate the “appropriate” use of healthcare resources. The development of a treatment plan depends on systematic assessment that should, whenever possible, not only involve the patients but also their partners or other key family members.
Milder or briefer adjustment disorders can be managed by primary care staff without recourse to specialist referral. Education, advice, and reassurance are of value. It is important that primary care staff are familiar with the properties and use of the commoner antidepressant drugs, and the value of brief psychological treatments such as cognitive behaviour therapy, interpersonal therapy, and problem solving.
Patients with more enduring or severe symptoms will usually require specific forms of treatment, usually drug treatment. Staff should also be able to assess suicidal thinking and risk. For patients with suicidal ideation or those whose depression has not responded to initial management, specialist referral is the next step in management.
Antidepressants have been shown to be effective in treating major depressive disorder irrespective of whether the mood disturbance is “understandable.” There have been far fewer trials of antidepressants in patients who are also physically unwell, but the available evidence is in keeping with the treatment of depression generally.
One of the commonest questions is which antidepressant should be used. For non-specialists, the range of available drugs, and the claims made about them can be bewildering. There are four main classes of antidepressant
- Selective serotonin reuptake inhibitors
- Monoamine oxidase inhibitors
- Others (noradrenaline reuptake inhibitors).
Data from the Cochrane Collaboration and other systematic reviews show that the differences in overall tolerability between different preparations is minimal. In general, patients are slightly less likely to drop out of trials because of unacceptable side effects when taking a selective serotonin reuptake inhibitor but are slightly less likely to drop out because of treatment inefficacy when taking a tricyclic. Rather than continuously experimenting with a range of different drugs, clinicians should stick to prescribing one drug from each class in order to become familiar with their dosing regimens, actions, interactions, and side effects. Clinicians should also be aware that in certain situations one class of drug may be more advisable than others.
The debate about different preparations has obscured a potentially more important issue—that of drug dose and compliance. Most prescriptions for antidepressants are for inadequate doses and for inadequate time periods. This problem is compounded by only a minority of patients complying with the prescribed treatment. A recent household survey by the Royal College of Psychiatrists showed that many people believed that antidepressants were addictive and could permanently damage the brain.
To treat patients successfully with antidepressants, doctors must be able to show their patient that they have understood the patient's problems, considered the issues, and are advising the best available treatment (see previous articles). Before starting treatment, patients should be given an explanation of side effects and be reassured that side effects tend to be worse during the first two weeks of treatment and then diminish. They need to be warned that they are unlikely to feel benefits from treatment in the first four weeks. They should be given follow up appointments during this period in order to encourage compliance.
After initial treatment has led to remission of symptoms, subsequent treatment can be divided into two phases. Firstly, four to six months of continuous treatment at full dose are necessary to consolidate remission and prevent early relapse. Secondly, consideration must be given to preventive maintenance treatment, to reduce the risks of recurrence of depression. This is usually indicated if the patient has had two or more episodes of depression within the past five years. Psychological treatment may also help to prevent recurrence and can be used in combination with drug treatment.
Problem solving in psychological treatment
- Define and list the problems
- Choose a problem for action
- List alternative courses of action
- Evaluate courses of action and choose the best
- Try the action
- Evaluate the results
- Repeat until major problems have been solved
Psychological treatment can range from discussion and simple problem solving to more specialised cognitive or dynamic behavioural psychotherapies. In many cases, brief treatment by non-specialists in primary and secondary care can be effective. Such interventions may include education and reassurance about the common reactions to the threats and losses associated with illness and empathic listening to patients' views, uncertainties, and beliefs about the illness. Education and advice about the medical condition and associated depression may prevent needless worry, reduce feelings of helplessness, and diminish irrational fears. Therapeutic approaches that support or promote active coping strategies are an important aspect of treatment in physically ill patients.
Evidence based summary
- Depressive illness is an important cause of morbidity and disability in physically ill patients
- All patients with depression should be examined for suicidal ideation
- Depression is treatable in physically ill patients
Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, Daniels M, et al. The functioning and well-being of depressed patients. Results from the medical outcomes study. JAMA 1989;262:914-9
Carson AJ, Best S, Warlow C, Sharpe M. How common is suicidal ideation among neurology outpatients? BMJ 2000;320:1311-2
Gill D, Hatcher S. Antidepressants for depression in medical illness. Cochrane Database Syst Rev 2000;(4):CD001312
Cognitive behavioural principles may be used by non-specialists to correct distorted thinking and to encourage behaviours that contribute to patients' sense of mastery and wellbeing. Training in briefer forms of treatment using cognitive behavioural principles for primary care staff may be a worthwhile investment.
Cognitive behaviour therapy, interpersonal therapy, and problem solving have all been shown to be effective for treating depression, although there has been only limited evaluation of their effectiveness in physically ill populations. Although time consuming by comparison with drug treatment, psychological treatment may reduce relapse rates and may be cost effective in the long run. Some patients may require preliminary treatment with drugs to enable them to make best use of psychological treatment.
- Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-IIIR psychiatric disorders in the United States: results of the national comorbidity survey. Arch Gen Psychiatr 1994;51,8-19
- Rodin G, Craven J, Littlefield C. Depression in the medically ill: an integrated approach. New York NY: Brunner/Mazel, 1991
- Royal College of Physicians, Royal College of Psychiatrists. The psychological care of medical patients: recognition of need and service provision. London: RCP, RCPsych, 1995
Depression is so common in physically ill patients that it is not feasible for all cases to be managed by mental health specialists. There are advantages to collaborative management with primary care staff working closely with mental health specialists. Community based mental health services may be less accessible to general hospitals and often lack specialist knowledge about assessment and treatment when an important physical illness is also present. Liaison psychiatry services are often well placed to provide support, training, and psychiatric expertise to general hospital patients in a timely fashion.