Although most persons with depression can be successfully treated with medications and/or psychotherapy, many do not seek treatment. Left untreated, depression leads to deterioration of interpersonal, social, and vocational functioning, which results in loss of productivity, psychosocial decline, and increased mortality.1,2
Here I outline the treatment options for depression, including complementary therapies. In a previous article (CONSULTANT, July 2007), I discussed diagnosis.
THE CASE FOR TREATING DEPRESSION
Antidepressant medications and psychotherapy are effective treatments for major depression. Patients who have dysthymic disorder may also benefit from antidepressants.3,4 Those with minor depression (characterized by fewer than 5 depressive symptoms that persist for less than 2 years) may have higher recovery rates with specific treatment (combined medication and psychological intervention) or with supportive care and monitored follow-up appointments.5
If normal bereavement does not resolve, it can lead to major depression. Thus, consider antidepressant therapy for grieving patients whose symptoms of depression last longer than 2 months.6
Treat depression aggressively in patients with comorbid medical conditions. Depression increases patients' sensitivity to existing medical conditions and could lead to poorer self-care, and subsequently worsen the prognosis associated with disorders such as cardiovascular disease, diabetes, and cancer.6 In addition to ameliorating depressive symptoms, appropriate antidepressant therapy improves the patient's overall condition.6,7
Mild cognitive impairment, poor concentration, and psychomotor retardation have been associated with both depression and dementia. A trial of antidepressant treatment is warranted in patients with dementia who also meet the diagnostic criteria for major depression. Older patients with new onset of depression may be at risk for dementia if their depression is not promptly and appropriately treated.6
Other psychiatric disorders frequently coexist with depression. In patients with concurrent anxiety, treat the depression first because such intervention may ameliorate the symptoms of both disorders.8,9 Refer patients with a history of mania, psychosis, or other major psychiatric illness for psychiatric evaluation. Substance abuse, which is common among depressed patients, is not an absolute contraindication to antidepressant treatment.6,10 Appropriate and timely treatment of depression may lead to reduced use of tobacco, alcohol, and possibly illicit drugs.6,10
Depression varies in severity and duration.11,12 The initiation of a specific treatment depends on the probability of a spontaneous recovery in a 2- to 4-week period. Patients who have moderate to severe symptoms, substantial functional impairment, or a long duration of illness are unlikely to recover and may require immediate psychiatric treatment. Patients with less severe or less persistent symptoms may be appropriate candidates for psychosocial and spiritual interventions with reevaluation in 2 to 4 weeks. The persistence of symptoms after 4 weeks of careful monitoring and psychosocial supportive measures warrants initiation of treatment.3
Patient education. Because mental illness—including depression—is often stigmatized, patients with depression may view themselves as emotionally weak or as having character defects.6 Educate patients about the roles of biological and psychosocial factors, stressful events, and inherited predisposition in causing depression. Help depressed patients understand that their condition results from a combination of biological vulnerability and accumulated psychosocial stressors. Emphasizing the high prevalence of depression may also help decrease the stigma associated with this illness.
Some patients focus on physical symptoms and interpret a diagnosis of depression as a decision to attribute their problems to a mental disorder. Explain that physical symptoms are characteristic of depression. In addition, effective relief of depression often makes chronic illness and physical symptoms more bearable.
Exploring treatment options. In primary care settings, up to 60% of depressed patients respond to initial pharmacological therapy or psychotherapy.11 The choice usually depends on treatment availability and the patient's preference. Although some evidence suggests that pharmacotherapy may be more effective than psychotherapy for the treatment of severe depression, this evidence has not yet been established clearly in primary care settings.13 Combined pharmacotherapy and psychotherapy may be the treatment of choice for patients with recurrent depression and for those whose condition has not responded to either treatment alone.6
Supportive interventions. Primary care providers may not have the luxury of time or the formal training to provide psychotherapy; however, they can initiate interventions to alleviate the symptoms of depression.6 The goals of such interventions are to provide support and to counteract feelings of helplessness and hopelessness. This could be achieved by encouraging patients to schedule relaxing or enjoyable activities every day, and by identifying exaggerated negative or self-critical thoughts. Consider offering brief supportive counseling as initial treatment for patients with mild depression or as an adjunct to pharmacotherapy.14 The objective of supportive interventions is to reduce the effects of depression and to improve general physical and mental health. Resources are listed on page 852.6,15
Although the mechanism of action of antidepressants is not fully understood, all classes of antidepressants can relieve depressive symptoms.6Table 1 and Table 2 summarize the various classes of antidepressants with their main neurotransmitter actions.3,6,16-21 Antidepressants differ mainly in their side-effect profiles and in their usefulness in treating comorbid conditions, such as generalized anxiety disorder, panic disorder, posttraumatic stress disorder, obsessive-compulsive disorder, and pain syndromes.16,22 Guidelines for the use of antidepressants in children, adolescents, and pregnant women are discussed in the Box.