The Role of the Family Physician in Managing Depression
Cognitive Behavioural Therapy is well established in secondary care but is not widely available in primary care. Its basis is the idea that emotional problems are due to maladaptive thoughts and beliefs and self-defeating behaviours. Therapy usually lasts between six and sixteen sessions, and aims to change the way the patient thinks about themselves or their situation, and the way they behave. Some trials show it is effective in primary care, but in the short term only. There is evidence that adding this therapy or interpersonal therapy to drug treatment is more effective than either alone, but only in severe depression, with no such effect in mild to moderate depression.

Problem Solving Therapy is a structured treatment, which aims to help people to identify and solve their inter-personal and social problems. It has been shown to be effective when administered in primary care when given by general practitioners with special training. 
Interpersonal therapy is a brief supportive therapy linking recent problems in interpersonal relations to the mood. It is not widely available. It has been shown to be as effective as Cognitive Behavioural Therapy. Psychodynamic therapies look at the origins of present difficulties in the person's early experiences and relationships. Sessions are usually weekly, and can last from several weeks to years. They have been shown to be effective in specialist centres. Exercise has been reported as being beneficial in the treatment of depression, but probably only as an adjunct to other therapies, and not alone.[7]

Pharmacological Treatment
Research has shown drug treatment to be effective in the acute treatment of all grades of depression, however the greatest benefit is seen in moderate to severe illnesses. There are a number of different drugs available and the choice can be tailored to the individual patient depending on the way their illness manifests itself and how he or she responds. 

Patients must be fully involved in understanding the treatment possibilities and know what to expect. Antidepressants are unlikely to have a noticeable effect in under two weeks. One of the biggest reasons for treatment to fail is because the drugs are not taken in sufficiently high dosage and for the correct length of time. This is often either because the patient was expecting to feel better more quickly and stops taking the tablets or because he or she starts to feel a little better and feels that treatment is no longer required. In fact treatment usually needs to 		 continue for four to six months, a lot longer than most other treatments an individual might have experienced before. Working closely with the patient and carers with regular reviews will help to achieve the maximum benefit.[7] 

The basis of the pharmacological treatment is to replace the missing chemicals (e.g. 5-hydroxytryptamine (5HT) and Noradrenaline (NA)) with antidepressant medications. Noradrenaline (NA) is the neurotransmitter most closely associated with motivation, where as 5-hydroxytryptamine (5HT) is most closely associated with anxiety and repetitive behaviour such as ruminations and compulsions. Antidepressants are classified into several groups; the tricyclic antidepressants (TCA), monoamine oxidase inhibitors (MAOI), reversible inhibitors of monoamine oxidase type A enzyme (RIMA), selective serotonin reuptake inhibitors (SSRI), selective serotonin and noradrenaline reuptake inhibitors (SNRI) and noradrenaline serotonin selective antidepressants (NASSA). 

There are several factors to be considered when selecting an antidepressant agent. Some factors are related to the patient such as; age, sex, previous patient or first degree relative response to antidepressants, cardiovascular and medical status and target symptoms of depression. Other factors are related to the antidepressant agent, like side effects, overdose safety, simplicity of use, cost, drug interactions and familiarity and comfort of the family physician with the drug[1]. 

How To Overcome Treatment Resistance
Partial response or non-response to antidepressant medications are common problems in patients with depression. Between 10-30 percent of patients are partially or totally resistant to treatment[8]. In those patients the family physician should review the diagnosis and check that the patients are taking the medication prescribed in the dosage prescribed[1]. Some factors are involved in treatment-resistance such as undiagnosed medical conditions (e.g. hypothyroidism and anaemia), non-psychiatric drugs like methyldopa, beta blockers and reserpine which may cause or exacerbate depression, comorbid psychiatric disorders (e.g. eating disorders, substance abuse or dependence and depression subtypes), side effects of the antidepressant and poor compliance.
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