How should primary care physicians treat patients with symptoms of depression?
Refreshingly, these guidelines are labeled as information for not only health professionals, but also for people with depression, their families, and caregivers. The authors emphasize that, other than in the presence of suicidal ideation and intent, the diagnosis of depression is more than simply ticking boxes. They also highlight the primacy of an ongoing relationship between clinician and patient to make the diagnosis and to decide, together, on the best treatment. For less severe depression, guided self-help, group or individual therapies, or other nondrug treatments are first-line therapy; drug treatment comes in ninth of 11 options. CBT and drug treatment, together or alone, are starting points for the treatment of more severe depression. See the links in the synopsis for graphic overviews to share with your patients while you are discussing treatment. (LOE = 5)
Overuse alert: This POEM aligns with the Canadian Psychiatric Association’s Choosing Wisely Canada recommendation: Don’t routinely use antidepressants as first-line treatment for mild or subsyndromal depressive symptoms in adults.
These guidelines are based on a systematic review of evidence conducted by a technical group. Mental health and primary care clinicians, along with lay members and administrators without financial conflicts of interest, made up the committee. They considered evidence of effectiveness, safety, cost, and availability, filling in with expert opinion when writing their recommendations. The guidelines recommend an assessment that "does not rely on symptom count . . . but also takes into account severity of symptoms, previous history, duration and course of illness.” Functional impairment is also a part of the diagnosis. Treatment guidelines are different for first episodes of less severe and more severe depression; for both instances, the authors list options, including no treatment, in order of preference. For less severe depression, initial options include guided self-help and group cognitive behavioral therapy (CBT) or group behavioral activation (see graphic overview). For more severe depression, start with a combination of individual CBT with drug therapy, or CBT, individual behavioral activation, or antidepressant alone (see overview). Based on expert opinion, lithium and antipsychotics are offered for patients who do not respond to trials of the first-line options. To prevent relapse, the group suggests discussing continued treatment for people at low risk of recurrence. For patients at higher risk, they suggest either continuing the same treatment and dose or switching from medication therapy to psychological therapy or, if a combination of therapy is used, backing off to a single psychological or medication treatment.
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine