Just a couple of well-chosen questions can help you uncover feelings that could spiral toward major depression and suicidal thoughts.
Jane, 55, is divorced and works as an accountant for an automobile dealer rumored to be on the verge of bankruptcy. At one of two annual visits to monitor her hypertension, Jane says that her mother died recently and she has had to put her father in a nursing home. His house — where Jane grew up — will have to be sold to cover the cost of his care. Her BP is 170/95 mm Hg, and she’s lost 10 lb since her last visit, without dieting. She complains that she can’t get a good night’s sleep and admits that she’s been smoking heavily. Jane seems depressed, and you think she would benefit from antidepressant medication.
Whenever patients with conditions requiring straightforward management, such as diabetes, asthma, or hypertension, mention feeling “really tired” or say they are unwell or unable to sleep, clinicians should be alert to the possibility of depression. One out of 10 men and one out of four women will suffer a major depressive episode at some point in their lives. Despite its prevalence, depression is picked up in the clinician’s office in only about 20% of cases. Moreover, even when clinicians do raise the issue, many patients resist the diagnosis. How can a busy practitioner keep those at risk from spiraling downward into serious and possibly dangerous depression?
Universal screening, appropriate treatment
One thing clinicians can do is screen for depression at each visit. New York City has asked all primary-care clinicians to use the Patient Health Questionnaire (PHQ)-2, a simple two-item questionnaire that asks, “Over the past two weeks, have you often been bothered by (1) Little interest or pleasure in doing things? (2) Feeling down, depressed, or hopeless?” A positive response to one or both questions prompts the clinician to follow up using the more detailed PHQ-9, a nine-item, self-administered questionnaire (Figure 1). Universal screening can help destigmatize both diagnosis and treatment.
For patients who have never taken an antidepressant, start with the lowest available dose, and if no side effects develop, escalate dosage per the Physicians’ Desk Reference. Sertraline, for example, comes in 25-mg tablets and has an effective dosage range of 50-200 mg/day. For those who experience few or no side effects, the dose can be increased in 25- to 50-mg increments every five to seven days, enabling an effective dose to be reached within two weeks.
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For some antidepressants, the starting dose is the final dose. Fluoxetine, for example, is often effective at 20 mg daily, a common starting dose. Similarly, escitalopram is often effective at 10 mg daily — again, the starting dose.Patients starting antidepressant medication will typically demonstrate a response within three to six weeks. Absent or partial response at six weeks may indicate the need to switch medication or add a second agent. A psychiatrist can help select a medication that produces the fewest side effects while maximizing the chance for response (see “The right treatment helps banish thoughts of suicide” above for an illustrative case study). Clinicians should consider psychiatric referral of patients who have not responded to a second agent after 12 weeks. Prompt psychiatric referral is indicated for patients with suicidal ideation, profound loss of function (e.g., unable to work), or severe neurovegetative symptoms, such as extreme weight loss.
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Tim, 29, is married and has three children. Last year, Tim moved into the community to join a local law firm. At that time, he asked you to write a prescription for antidepressant medication, which he has been taking since graduating from law school. Tim’s depression was sufficiently severe during his schooling that he had to be briefly hospitalized for suicidal ideation. Now, Tim makes an appointment to discuss his medication regimen. At the appointment, he tells you that his mood has been stable; he feels he has been on medication “long enough” and wants to know whether you think he will become depressed again if he discontinues it. What advice should you give?
Helping patients stay on their antidepressant can be crucial to preventing relapse. Studies show that the risk of relapse is dramatically reduced when patients remain on antidepressants for at least six months once the patient is no longer depressed. And for patients with two or more lifetime episodes of depression, antidepressants may need to be continued for at least three years following resolution of symptoms. Explaining to patients that medication is working “silently” to prevent relapse can make the difference between continued stable mood and recurrent depressive episodes.
It is important to tell patients you want to hear about all side effects, including potentially embarrassing sexual episodes. Gradually escalating the medication dose, adjusting a standing dose, or augmenting or cross-titrating antidepressants can effectively manage most side effects.
For example, bupropion and mirtazapine have lower rates of sexual side effects than typical selective serotonin reuptake inhibitors (SSRIs), such as sertraline or paroxetine. If a patient experiences sexual side effects on an SSRI, you can start bupropion while continuing the SSRI. If side effects persist, slowly taper the SSRI while continuing bupropion. After a couple of weeks, the patient should be free of sexual side effects without loss of antidepressant efficacy.
Primary and secondary preventionUnfortunately, there is little evidence that depression is preventable. Studies show that a clear stressor, such as job loss, failed romance, or medical illness, is found in only 50% of depression cases. While this implies that many people are vulnerable to developing depression in the wake of significant stress, just as many people become depressed for no clear reason. A family history of depression or suicide significantly increases the risk for depression, and MRI studies support the hypothesis that depression is most often and fundamentally an inherited disorder of the brain; specifically the limbic system and its connections to the prefrontal cortex. But the news is not all bad. Clinicians can give patients sound advice on how to optimize their mood and, most importantly, what symptoms to look for that may herald the onset of a depressive episode.
In addition to appropriate medication, offer patients these mood-boosting suggestions:
• Exercise regularly. Many studies have shown that physical activity improves mood.
• Limit alcohol. Alcohol-induced euphoria is typically followed by depression. And even one drink hours before bedtime can disrupt normal sleep, leading to frequent awakenings, fatigue, and irritability.
• Get enough sleep. Chronic sleep deprivation is associated with anxiety, irritability, depression, and poor work performance. Advise patients to go to bed earlier, keep the room cool, and have a small snack 30 minutes before retiring. Try to avoid prescribing hypnotics since many patients develop tolerance, which increases the risk for abuse.
• Be vigilant. Patients who have experienced prior major depressive episodes should be alert to changes in attention, concentration, sleep, appetite, energy, and mood. While sadness is a normal and expected part of life, persistent sadness lasting more than two weeks is cause for concern and warrants evaluation by you or a mental-health professional.
• Beware of post-holiday depression. At holiday time, many patients will encounter stressful situations involving family and friends. Typically, patients susceptible to depression will summon reserves of emotional fortitude to get through this difficult time, but symptoms may appear in the weeks and months that follow.
• Mood-boosting activities. Support groups, tapes, and books can help. Three of our favorite books include Feeling Good: The New Mood Therapy by David Burns, MD (Harper Collins, 1999); Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life, by Jon Kabat-Zinn, PhD (Hyperion, 2005); and Understanding Depression: A Complete Guide to Its Diagnosis and Treatment, by Donald F. Klein, MD, and Paul H. Wender, MD (Oxford University Press, 2005).