Mental health articles

Much depressive illness of all types is successfully treated in primary care. The main reasons for referring depressed patients to secondary mental health services are that the condition is severe, failing to respond to treatment, complicated by other factors (such as personality disorder) or presents particular risks.

The presence of agitation has been shown to mask psychotic features. Patients with marked psychomotor retardation are also often diffi cult to treat in primary care. Medication versus psychotherapy Basic treatment for mild, moderate and severe depression is generally similar. The principal decision is whether to treat Reasons for referral to specialist psychiatric services

High risk of suicide Failure to respond to usual treatment Diagnosis is diffi cult Comorbid conditions in which the other illness or its treatment makes treatment of depression problematic (for example, serious physical illness or personality disorder) Patients with psychotic depression who may require either combinations of different antidepressants or electroconvulsive therapy Patients with bipolar disorder who represent a higher suicide risk during depressed phases and may need careful monitoring of mood stabiliser medication drugs or a talking therapy. Surveys have shown that most patients in primary care settings would prefer a talking therapy, but evidence of effectiveness is limited to particular forms of psychotherapy.

In mild depression, a patient’s response to antidepressants may be no better than to placebo, and bibliotherapy (using self-help manuals) or cognitive behavioural therapy (CBT) are more useful. For moderate depression, CBT and antidepressants are equally effective, and the two combined are superior to either alone. For more severe depression, antidepressant drugs are more effective. Cognitive behavioural therapy is a ‘brief’ focused psychotherapy requiring from six to 20 sessions, and its availability may be limited in some areas. Drug treatment The use of tricyclic antidepressants at doses well below those that are therapeutically effective (i.e. less than 125 mg daily imipramine equivalent) has often been reported, especially in primary care. Chopping and changing treatments before giving any one a chance to work (at least six to eight week trial) is also common. Effective antidepressant drugs have been available since the 1950s. The choice is now between traditional tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), and more recent selective serotonin reuptake inhibitors (SSRIs), selective serotonin-noradrenaline reuptake inhibitors (SNRIs) and other monotherapy antidepressants (e.g. reboxetine, mirtazapine).

Newer drugs were developed ‘rationally’ to be more selective in their actions than the older antidepressants, and, hence, have far fewer serious side effects than the TCAs or the MAOIs. However, some older drugs – such as desipramine, maprotiline and nortriptyline –  are also selective for noradrenaline reuptake blockade. The differences between drugs lie primarily in their side effects and their potential interactions with other drugs.

Side effects, in particular anticholinergic effects and weight gain, are thought to have a major effect on the frequency with which patients do not take antidepressants as prescribed. Careful clinical studies show large differences between older and newer antidepressants, with much higher non-adherence rates in patients taking the older drugs with more side effects. This merely demonstrates what is clinically obvious – that patients prefer taking drugs with fewer side effects.

Tags: depression, treatment