Major Depressive Disorder in the Primary Care Setting
Devin Pinaroc, FNP-C
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria defines major depressive disorder as a combination of certain, specific symptoms, like depressed mood or loss of interest/pleasure, that present during the same 2-week period, not caused by a substance or another medical condition, and create clinically significant distress or impairment in social, occupational, or other important functioning (Maurer et al., 2018).
The lack of access to specialty providers, stigmatization regarding mental health disorders, and associated costs utilizing some mental health resources drives patients to seek initial treatment from their primary care provider. Overall, an estimated 60% of mental health care delivery occurs in the primary care setting, and most patients seek (Park, L. T., & Zarate, 2019).
Screening Recommendations
The United States Preventive Services Task Force recommends regular screening for depression in the general population when there are adequate systems in place for treatment and follow-up (2). While there is not a single screening instrument proven to be most efficacious, the two- and nine-item Patient Health Questionnaires (PHQs) are the most widely used (2). Primary care providers should consider incorporating these questionnaires or some other screening tools with each new patient visit, yearly preventive exams, and during mental health follow-up assessments. Not only are they helpful in identifying depressive disorders, they can help with assessing treatment response and condition status.
Treatment Options
The initial treatment for unipolar major depressive disorder should be a combination of pharmacology and psychotherapy or a trial of each one independently, depending on severity (Rush,2020). Randomized controlled trials (RCTs) have displayed efficacy with combination pharmacology and psychology over one alone, but pharmacology alone and psychotherapy alone still prove effective in treating depression (Rush, 2020). Primary care clinicians should also consider that many RCTs showing the efficacy of pharmaceuticals only used patients with moderate to severe depression (Park, L. T., & Zarate, 2019).
Psychotherapy. Initiating psychotherapy alone and monitoring symptoms for mild to moderate depression treatment may be appropriate, particularly given the potential for unpleasant medication side effects (Park, L. T., & Zarate, 2019). There are many types of psychotherapy proven successful in the treatment of depression, but one has not emerged as superior (Rush, 2020). Consider the exacerbating factors, comorbidities, and patient situation when recommending the appropriate type of psychotherapy (Park, L. T., & Zarate, 2019). For example, interpersonal psychotherapy may help with relationship problems, behavioral activation can increase motivation, and cognitive behavior therapy may help with distorted thoughts that exacerbate depression (Park, L. T., & Zarate, 2019).
Regardless of type, adherence to psychotherapy is often a limiting factor, so regular follow up visits are key (Rush, 2020).
Pharmaceuticals. Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), atypical antidepressants (bupropion), and serotonin modulators are generally the first line pharmaceuticals for major depressive disorder (Rush, 2020). Multiple RCTs prove that antidepressants are highly effective in reducing and remitting depressive symptoms, and, given that they are often characterized by their low cost and ease to tolerate, patients with mild-to-moderate depression may find relatively quick benefits (Rush, 2020). A singularly superior SSRI or SNRI has not been identified for treating depression as each medication has its advantages (Park, L. T., & Zarate, 2019). Escitalopram and sertraline are reasonable SSRIs for primary care providers to suggest as initial treatment given their tolerability and low potential for side effects (Rush, 2020). SNRIs can be advantageous for those with anxiety and chronic pain, but can be costly and difficult to tolerate (Park, L. T., & Zarate, 2019). Bupropion is useful for tobacco users and those worried about sexual side effects (Rush, 2020).
Encouraging a healthy lifestyle – regular exercise, adequate sleep, nutritious diet, and stress management – and ensuring other comorbidities are controlled may optimize interventions. Mindfulness and meditation has recently been popular in mental health treatment plans and may be beneficial to some patients.
Telemedicine Delivery in Mental Health
Recently, light has been shed on the lack of education regarding the prevalence of depression and limited mental health resources available to all patient populations regardless of their socioeconomic status or location. Psychotherapy is often not covered by insurance, inconvenient, and stigmatized. The vast amount of pharmaceuticals can create uncertainty and hesitancy for primary care providers. However, fueled by the need to social distance, the development of mental health telemedicine platforms seems to help bridge this gap in mental health resources. Websites and phone apps, like TalkSpace™ or BetterHelp™, bring access to anyone with internet access. These platforms provide completely remote tele-therapy, access to support groups, and mental health seminars. While still new, remote delivery of psychotherapy is proving just as effective as face-to-face delivery with the advantage of being convenient and cost effective (Simon et al, 2014).
Learn More and Earn CE
We have many courses on our Learning Center on the topic of depression and depression treatments. Click here for a list of courses.
Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: Screening and Diagnosis. American family physician, 98(8), 508–515.
Park, L. T., & Zarate, C. A., Jr (2019). Depression in the Primary Care Setting. The New England journal of medicine, 380(6), 559–568. https://doi.org/10.1056/NEJMcp1712493
Simon GE, Ludman EJ, Tutty S, Operskalski B, Korff MV. Telephone Psychotherapy and Telephone Care Management for Primary Care Patients Starting Antidepressant Treatment: A Randomized Controlled Trial. JAMA. 2004;292(8):935–942. doi:10.1001/jama.292.8.935
Take Away Points Patients respond differently to therapeutic interventions based on genetic variations found across populations Genomic medicine has a …
Major Depressive Disorder in the Primary Care Setting
Devin Pinaroc, FNP-C
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria defines major depressive disorder as a combination of certain, specific symptoms, like depressed mood or loss of interest/pleasure, that present during the same 2-week period, not caused by a substance or another medical condition, and create clinically significant distress or impairment in social, occupational, or other important functioning (Maurer et al., 2018).
The lack of access to specialty providers, stigmatization regarding mental health disorders, and associated costs utilizing some mental health resources drives patients to seek initial treatment from their primary care provider. Overall, an estimated 60% of mental health care delivery occurs in the primary care setting, and most patients seek (Park, L. T., & Zarate, 2019).
Screening Recommendations
The United States Preventive Services Task Force recommends regular screening for depression in the general population when there are adequate systems in place for treatment and follow-up (2). While there is not a single screening instrument proven to be most efficacious, the two- and nine-item Patient Health Questionnaires (PHQs) are the most widely used (2). Primary care providers should consider incorporating these questionnaires or some other screening tools with each new patient visit, yearly preventive exams, and during mental health follow-up assessments. Not only are they helpful in identifying depressive disorders, they can help with assessing treatment response and condition status.
Treatment Options
The initial treatment for unipolar major depressive disorder should be a combination of pharmacology and psychotherapy or a trial of each one independently, depending on severity (Rush,2020). Randomized controlled trials (RCTs) have displayed efficacy with combination pharmacology and psychology over one alone, but pharmacology alone and psychotherapy alone still prove effective in treating depression (Rush, 2020). Primary care clinicians should also consider that many RCTs showing the efficacy of pharmaceuticals only used patients with moderate to severe depression (Park, L. T., & Zarate, 2019).
Psychotherapy. Initiating psychotherapy alone and monitoring symptoms for mild to moderate depression treatment may be appropriate, particularly given the potential for unpleasant medication side effects (Park, L. T., & Zarate, 2019). There are many types of psychotherapy proven successful in the treatment of depression, but one has not emerged as superior (Rush, 2020). Consider the exacerbating factors, comorbidities, and patient situation when recommending the appropriate type of psychotherapy (Park, L. T., & Zarate, 2019). For example, interpersonal psychotherapy may help with relationship problems, behavioral activation can increase motivation, and cognitive behavior therapy may help with distorted thoughts that exacerbate depression (Park, L. T., & Zarate, 2019).
Regardless of type, adherence to psychotherapy is often a limiting factor, so regular follow up visits are key (Rush, 2020).
Pharmaceuticals. Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), atypical antidepressants (bupropion), and serotonin modulators are generally the first line pharmaceuticals for major depressive disorder (Rush, 2020). Multiple RCTs prove that antidepressants are highly effective in reducing and remitting depressive symptoms, and, given that they are often characterized by their low cost and ease to tolerate, patients with mild-to-moderate depression may find relatively quick benefits (Rush, 2020). A singularly superior SSRI or SNRI has not been identified for treating depression as each medication has its advantages (Park, L. T., & Zarate, 2019). Escitalopram and sertraline are reasonable SSRIs for primary care providers to suggest as initial treatment given their tolerability and low potential for side effects (Rush, 2020). SNRIs can be advantageous for those with anxiety and chronic pain, but can be costly and difficult to tolerate (Park, L. T., & Zarate, 2019). Bupropion is useful for tobacco users and those worried about sexual side effects (Rush, 2020).
Encouraging a healthy lifestyle – regular exercise, adequate sleep, nutritious diet, and stress management – and ensuring other comorbidities are controlled may optimize interventions. Mindfulness and meditation has recently been popular in mental health treatment plans and may be beneficial to some patients.
Telemedicine Delivery in Mental Health
Recently, light has been shed on the lack of education regarding the prevalence of depression and limited mental health resources available to all patient populations regardless of their socioeconomic status or location. Psychotherapy is often not covered by insurance, inconvenient, and stigmatized. The vast amount of pharmaceuticals can create uncertainty and hesitancy for primary care providers. However, fueled by the need to social distance, the development of mental health telemedicine platforms seems to help bridge this gap in mental health resources. Websites and phone apps, like TalkSpace™ or BetterHelp™, bring access to anyone with internet access. These platforms provide completely remote tele-therapy, access to support groups, and mental health seminars. While still new, remote delivery of psychotherapy is proving just as effective as face-to-face delivery with the advantage of being convenient and cost effective (Simon et al, 2014).
Learn More and Earn CE
We have many courses on our Learning Center on the topic of depression and depression treatments. Click here for a list of courses.
Want to know more…
Major Depressive Disorder in Primary Care: Strategies for Identification
Psychological Treatment of Depression in Primary Care: Recent Developments
The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Trial: A Review
Cognitive behaviour therapy for depression in primary care: systematic review and meta-analysis | Psychological Medicine | Cambridge Core
Effect of Treatments for Depression on Quality of Life: A Meta-Analysis
PHQScreeners.com
A growing wave of online therapy
References
Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: Screening and Diagnosis. American family physician, 98(8), 508–515.
Park, L. T., & Zarate, C. A., Jr (2019). Depression in the Primary Care Setting. The New England journal of medicine, 380(6), 559–568. https://doi.org/10.1056/NEJMcp1712493
Rush, A. J. (2020, November). Unipolar major depression in adults: Choosing initial treatment. UpToDate. https://www.uptodate.com/contents/unipolar-major-depression-in-adults-choosing-initial-treatment?search=depression+treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H432086717.
Simon GE, Ludman EJ, Tutty S, Operskalski B, Korff MV. Telephone Psychotherapy and Telephone Care Management for Primary Care Patients Starting Antidepressant Treatment: A Randomized Controlled Trial. JAMA. 2004;292(8):935–942. doi:10.1001/jama.292.8.935
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