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The Role of the Family Physician in Managing Depression |
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| The family physician's
previous clinical experiences, his attitude to psychological complaints,
his factual knowledge about depression and behaviour during
consultation also contribute to the problem. Busy clinics and
limited consulting time are also factors. However, the standard
consultation in general practice is usually adequate for the recognition and
management of depression. Having more time is less important than making
the best of it. [5] DIAGNOSTIC CRITERIA AND CLASSIFICATION OF DEPRESSION The family physician should be alert and clear about the diagnostic criteria of depression to avoid under or overdiagnosis. This is best done by applying the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. It includes nine symptoms in the diagnosis of major depression. These symptoms are: 1-Depressed mood, 2-Loss of interest in all activities, 3-Poor appetite or loss of weight, 4-Insomnia or hypersomnia, 5-Psychomotor agitation or retardation, 6-Loss of sexual drive, 7-Fatigue or loss of energy, 8-Lack of concentration, 9-Recurrent thoughts of death/suicide ideation/wishes to be dead or suicidal attempt. Depression is diagnosed if either depressed mood or loss of interest and pleasure are present, plus four or more of the other seven symptoms. These symptoms should be present for a minimum of two weeks and there should not be evidence of other primary disorders.[1,5] Depression can be classified into mild, moderate or severe cases based on the presenting symptoms. This is very helpful in the management plan. If the patient fulfills the diagnostic criteria but has no psychomotor agitation or retardation or suicidal risk this is classified as mild depression. If the patient has psychomotor agitation or retardation, but no suicidal risk, this is classified as moderate depression, but if the patient has suicidal risk this is classified as severe depression which is a psychiatric emergency. |
How to manage depressive patients The key in managing patients with depression is to build a solid therapeutic partnership by communicating interest, respect, support and empathy for the patient's emotional situation before turning to the prescription pad[4]. It is important to evaluate the severity of the illness. Is the patient at suicidal risk? Does he/she require inpatient assessment? Is referral to a specialist psychiatrist indicated?[2]. Usually mild cases need supportive psychotherapy and regular follow up only. Moderate cases in addition to the supportive psychotherapy, may require starting patients on a pharmacological agent. Severe cases are an indication for referral. Other causes of similar symptoms should be considered before starting the management plan. In some elderly patients, depression can be mistaken for dementia when changes in cognition result directly from changes in mood. This reversible condition is referred to as "pseudodementia"[6]. Supportive Psychotherapy A variety of mental health workers provide psychological therapies which may include: non-directive counselling, cognitive behavioural therapy, problem solving skills training, interpersonal therapy and psychodynamic therapy. All of these approaches are popular, but there are issues about individual preference, effectiveness and availability in general practice. Non directive counselling is widely available. It is usually given as a course of six to ten sessions. The best recent evidence shows that it is effective in at least the short term, but probably has no long-term effect on outcome. Women with postnatal depression have been found to be the group which responds best to this type of treatment. |
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