Treating Depression in the Primary Care Setting MHNet has adopted this guideline from the American Psychiatric Association’s (APA) Practice Guideline for the Treatment of Major Depression. This synopsis is provided as a service to primary care practitioners. This guideline summary is not designed to stand on its own and should be used in conjunction with the full text of the Practice Guideline which is available at the APA’s web site, www. psych.org. If you do not have access to this web site and would like a hard copy of the complete practice guideline, please contact MHNet’s Corporate Quality Improvement Department at (512) 347-7900.
Major depression is a common illness affecting roughly 15 per-
INITIATING ANTIDEPRESSANTS
cent of the population at sometime during their life. Most people with
major depression do seek professional help. For those who do, pri-
The first step is to get a thorough history of medication use and
mary care physicians remain the point of entry into the behavioral
response. In general, if a patient has shown a clear response to a
health system, even when managed behavioral health care organiza-
specific agent in the past, the same drug should be restarted. The
only exception would be a patient whose prior treatment was in the
remote past before the discovery of newer generation antidepressants.
Depression presents myriad chal enges to PCP’s. Successful
For these individuals, one may elect to try a newer drug with fewer
treatment of major depression requires a proactive and systematic
side effects than an older tricyclic or monoamine oxidase inhibitor
approach to detection and management through a combination of psy-
chotherapy and, often, medication. The therapy does not have to be
If there is no prior history of antidepressant responsiveness, most
sophisticated. Brief supportive therapy is sufficient for many individu-
physicians initiate therapy with a selective serotonin reuptake inhibitor
(SSRI). There are currently four FDA approved SSRI’s available for
the treatment of major depression (Celexa, Paxil, Prozac and Zoloft).
Primary care physicians have several functions with regards to
Of these, only Prozac currently has a generic substitute. It is recom-
major depression: they need to identify patients with the condition,
mended that PCP’s become familiar with one or two of these medica-
prescribe medications, provide supportive therapy, adjust medications
tions and use them as their first line drugs.
as necessary, continue maintenance medications if appropriate, refer
specific patients for psychiatric evaluation and counseling, and monitor
SSRI’s can be started at the full therapeutic dose (20mg/day for
Celexa, Paxil or Prozac, 50mg/day for Zoloft). However, many physi-
cians start at ½ dose for several days to minimize initial side effects.
EVALUATING PATIENTS
After several weeks, if there has been no response, an upward dosage
adjustment of 50-100% of the starting dose can be made. If there has
It is recommended that all PCP’s have some mechanism for rou-
been no significant response within six weeks, an alternative drug
tinely screening patients for major depression. This can be formalized
should be tried or a referral made to a psychiatrist.
by using a screening questionnaire (e.g. PrimeMD), or by routinely
including questions about depression in the review of systems. The
SUPPORTIVE THERAPY
PCP should be knowledgeable about the cardinal symptoms of de-
If the PCP does not refer the patient for counseling, then he or
she should provide the patient with supportive therapy. This should
include brief visits (15 to 30 minutes) once a week or every other week
for the first two months until the patient reports significant improve-
CONTINUATION MEDICATION
Once patients report significant benefit from medication therapy,
they should continue the antidepressant medication for at least nine
months. Patients should be counseled that premature discontinuation
of their medication can result in a prompt relapse. Fol ow up visits
Since many patients do not spontaneously report these symp-
should be based upon the need for continued supportive counseling
toms, it is important that the PCP ask direct questions of any patient
and the need to insure medication compliance. Most psychiatrists wil
who presents with a new onset of vague symptoms that are not clearly
see patients once a month for several months after they report signifi-
diagnostic of a specific medical condition.
cant improvement to encourage continued compliance with treatment.
After nine months, patients can be weaned of the SSRI (typically by
If the PCP identifies new onset major depression (or a recurrence
taking ½ the dose for a month then stopping). Some patients may
of major depression in a patient with a prior history), he or she should
experience physical withdrawal (particularly with the shorter acting
either refer for psychiatric evaluation or initiate supportive counseling
Paxil) that may necessitate more gradual withdrawal.
Treating Depression in the Primary Care Setting MA INT EN AN CE M ED ICA T I O N WHEN TO REFER
Patients who have had more than 3 episodes of major depres-
Patients should be referred for counseling if they have multiple or
sion (or two episodes if the depression was severe) should be consid-
severe life stressors in addition to their depressive illness. They
ered for maintenance antidepressant therapy. In weighing this deci-
should be referred if the depression is profound, overwhelming, and
sion, the physician should balance the relatively small risk of long-term
brief supportive contact is insufficient. If the depression is negatively
drug therapy against the significant risk of recurrent depression. De-
impacting the family, counseling may be helpful in addressing their
pression is usually quite incapacitating and is associated with signifi-
cant mortality due to suicide. Although some clinicians use lower dose
for maintenance therapy, as long as the patient reports no significant
Patients should be referred for psychiatric assessment if they are
side ef ects from their medication, lowering the dose is not warranted.
suicidal, psychotic, or possibly in need of hospitalization. They should
be referred if they have a secondary psychiatric condition such as
CHOOSING A DIFFERENT AGENT
active substance abuse, panic disorder, dysthymia or personality disor-
der. They should be referred if there has been no significant improve-
Outcome studies suggest that all antidepressants are effective in
ment in two months with a single antidepressant (3 months if two
about 60% of patients with major depression. Therefore, it is common
that a patient will not respond to the first agent prescribed. It is recom-
mend that PCP’s become familiar with one or more non-SSRI medica-
tions to use as a second line drug. Possible agents include Wellbutrin,
This practice guideline is not intended to be construed or to serve
Remeron, or Serzone. Wellbutrin should be initiated at a dose of
as a standard of medical care. Standards of medical care are deter-
100mg/day and titrated up to 150mg twice a day. Remeron should
mined on the basis of all clinical data available for an individual case
start at 15mg hs. As needed, one can adjust the dose up to 45mg hs.
and are subject to change as scientific knowledge and technology
Serzone is usually started at a low dose (100mg/day) and gradual y
advance and patterns evolve. These parameters of practice should be
increased to 300-450mg/day in divided doses or all at bedtime.
considered guidelines only. Adherence to them will not ensure a suc-
cessful outcome in every case, nor should they be construed as includ-
CONCOMMITTENT MEDICATIONS
ing all proper methods of care or excluding other acceptable methods
of care aimed at the same results. The practitioner, in light of the clini-
Antidepressants take several weeks before there is significant
cal data presented by the patient and the diagnostic and treatment
benefit. Therefore, it is frequently beneficial to give patients some im-
options available, must make the ultimate judgment regarding a par-
mediate symptomatic relief with anxiolytics during the day (Ativan,
ticular clinical procedure or treatment plan.
Xanax or Serax) and hypnotics at night for sleep (Ambien, Sonata,
Restoril). These should be for short-term use only (2-4 weeks). Since
REFERENCES
most of these drugs are short acting, patients should be advised about
rebound anxiety when they wear off. In particular, the short acting
These guidelines were adapted from the American Psychiatric
hypnotics (Ambien and Sonata) may not provide prolonged sleep for
Association’s practice guidelines [American Psychiatric Association:
Practice Guidelines the Treatment of Patients with Major Depressive
Disorder. Am J Psychiatry 2000; 157 (April suppl)]. The reader is re-
ELDERLY PATIENTS
ferred to the original article for detailed references as wel as the work
Special consideration needs to be given to elderly patients. This
includes increased sensitivity to antidepressant side effects especially sedation, agitation, unsteadiness, and confusion. Possible interactions with other medications should be considered before initiating therapy. Starting doses should be adjusted downward. One typically starts with ½ the usual starting dose of an antidepressant, ¼ the usual starting dose of an anxiolytic. The possibility of a medical condition causing or exacerbating the depression is increased in the elderly population. Therefore, one must be sure to exclude any underlying treatable physi-cal condition.
MHNet Behavioral Health
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