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The Role of the Family Physician in Managing Depression |
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| There are five
strategies for treating partial response or nonresponse to
antidepressant medications. These are Optimization, Drug Substitution,
Combination Therapy, Electroconvulsive Therapy (ECT) and Augmentation
Therapy. Optimization is prescribing the antidepressant in the best
possible way by maximizing the dose and duration of therapy, encouraging
compliance and keeping attention on the patient's psychosocial
situation. Drug Substitution is replacing an ineffective drug with a new
drug. Switching to a new drug keeps things simple and avoids potential
drug-drug interactions. Monotherapy might also be associated with
greater compliance. Some controlled studies have shown that when
patients are switched from one TCA to another TCA the response rate is
only 10 - 30 percent. When double-blind studies examined patients
switching to different classes of antidepressants ( e.g. SSRI to TCA),
however, response rates were higher at 40 -70 percent. Combination Therapy is concurrent administration of two or more antidepressant agents which may result in a different therapeutic response than monotherapy. However, there is no strong evidence suggesting the usefulness of this practice. Electroconvulsive Therapy (ECT) is still the most effective treatment for psychotic depression and severe refractory depression. The physician should not hesitate to recommend it and should reassure patients as to its appropriate and safe use under medically monitored conditions. Augmentation Therapy is adding a second agent, but one that is not routinely regarded as an antidepressant like lithium, thyroid hormone, the beta blocker pindolol and buspirone. This is to boost or magnify the effects of the original antidepressant.[8,9] |
When To Refer
Depressive Patients Psychiatric consultation may be sought to enhance the safety and effectiveness of the treatment if the patient has severe depression, substantial suicidal risk (Table1), associated psychiatric or physical disorders, or poor or partial response. Also the patient should be referred if the diagnosis is still unclear or if the patient needs an alternative treatment such as ECT. Follow-up: Depressed patients should be followed up regularly. The aim is to review the management plan, evaluate the symptoms and response and to assess the social support. The severity of the depression and the response to the treatment decide how frequent follow-up is required. As a start it is advisable to fix a weekly follow-up visit to support and encourage the patients and to assess compliance and the drug's side effects. Depressed patients cannot play the same part in managing their own care as patients with asthma or diabetes. Doctors may fear that because depressed people often have reduced self esteem they may lose insight into their own needs for treatment and fail to play their part in the management plan[10]. This should not be the case - the patients must be involved and incouraged to share in their management plan. Depression is a chronic illness, so relapses and recurrences are frequent. Therefore, long-term use of antidepressants is sometimes necessary. It is recommended for six to nine months after the first episode, one year after the second and indefinitely after the third. Patients are at risk of |
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