Managing depression for non-psychiatrists

[quickfeet]

I am an IM resident currently, and I live in a town where the average wait time to see a psychiatrist is over 6 months. In this particular town, I've noticed there are several family physicians and internists who refer to psychiatry anytime a first-line SSRI doesn't work. For example, I know a patient personally who was trailed on Prozac then Celexa with no response to either, and then she was referred out. She subsequently went without any treatment for several months.

I understand physicians (or mid-level providers) not being comfortable treating something and asking for expert help, but I feel that in places where your patients can expect to go without seeing a psychiatrist for over 6 months you need to do a little bit more than just try 1 or 2 drugs and give-up. Especially with how common depression is. So, I was curious if anyone would be willing to explain their general approach to mild-moderate unipolar depression refractory to SSRIs. What are the steps you take? I've heard of augmenting with Wellbutrin before switching SSRIs. Then switching to SSNRIs, etc. What is your general practice? Also when is it really appropriate to refer out for this issue even despite wait times? Thanks for your time.

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[splik]

mild to moderate depression should not be treated with drugs.

 

[DisorderedDoc417]

mild to moderate depression should not be treated with drugs.

Hmmm. Don’t think this is sound advice. Everything is case-by-case.

 

[wolfvgang22]

Hmmm. Don’t think this is sound advice. Everything is case-by-case.

What makes you say that? Splik is quoting well known, evidence based treatment recommendations. Psychotherapy is in fact first line treatment for mild to moderate depression.

 

[Crayola227]

I have a bunch of lifestyle intervention reccs, but that might not be up your alley

I have about an hour or so lecturing I do on light therapy, chronotherapy, sleep hygeine

I would definitely try light therapy, even outside of clear SAD, I think the risk/benefit analysis still favors it as long as you start low, go slow, and are mindful of any bipolarity in the patient. Some people it's as simple as a daylight bulb in the right spots.

Constipation and depression are 2 complaints where I think vitamin D supplementation is important. The data might not be behind me anymore for depression, but I keep curing chronic constipation so....

Melatonin for sleep often isn't a bad adjunct. It has effects on sleep quality, so even if a complaint isn't drift off insomnia, it can still help. Main side effects could be fatigue or very vivid nightmares, which usually go away after a week or so of terror-soaked nights.

A little more "out there" but depending on the picture, chronotherapy

Chicago Psychiatry Associates' Program in Psychiatric Chronotherapy

With any sleep deprivation schedule, you have to think about what that can do to mood and risk of bipolar disorder. Otherwise, I think it's fair to mention this intervention to a patient that would be stable enough for this.

I think these are reasonable non-pharmacologic interventions. Mild to moderate depression, this is about as exotic as you need. I stress the importance of sleep hygeine, avoiding all non-prescribed CNS acting substances - no MJ, little to no EtOH. Even caffeine depending. Exercise. Then I get kooky with light, vitamin D, melatonin.

A little psychotherapy, the above "natural" interventions/placebos, I think are good starts without using pills to try to get someone out of a mild funk and keep them there.

 

[cbrons]

mild to moderate depression should not be treated with drugs.

Ok so what about severe depression... or whatever the category is where using drugs is acceptable?

 

[tr]

The problem with nonpharmacological approaches in primary care is that they take time to implement. Explaning sleep hygiene, strategic light/dark exposure, coaching on the use of Calm Breathing, etc., all these things take time which the primary care physician often doesn't have in a 15-minute appointment.

OP how easy is it to find a therapist where you are? Early referral to a therapist (PsyD, PhD, LCSW, MFT, or whatever is available where you are) may be more efficient than waiting for a psychiatry appointment.

Other than that, the main thing I have noticed about non-psychiatrists using SSRIs is that they often don't have a good sense of the time frame required for response. Four weeks is the minimum adequate trial for an SSRI. Side effects, especially GI upset, peak early, before benefit kicks in. It's important to push past that. GI upset and other SE can be minimized by starting low and increasing slowly. If no benefit after 4-6 weeks I usually switch rather than augment. There's no point in continuing something that isn't working, it just results in unnecessary polypharmacy. The Star*D trial showed that augmentation is no more effective than switch in cases of nonresponse to first treatment alternative.

 

[WisNeuro]

OP how easy is it to find a therapist where you are? Early referral to a therapist (PsyD, PhD, LCSW, MFT, or whatever is available where you are) may be more efficient than waiting for a psychiatry appointment.

If they are in any decent-sized area (100k+) probably fairly easy. Most metro areas are fairly saturated. Past couple of places I've lived, and currently, when we've had to refer out, we can usually get someone an intake somewhere within a week or two.

 

[DisorderedDoc417]

What makes you say that? Splik is quoting well known, evidence based treatment recommendations. Psychotherapy is in fact first line treatment for mild to moderate depression.

Mild I’ll give you. Moderate with a few comorbidities and CBT isn’t guaranteed. Literature also says the two together are more effective than either one alone. I love splik, just felt like it was overly generalized and doesn’t help someone in the OPs situation.

 

[DisorderedDoc417]

What makes you say that? Splik is quoting well known, evidence based treatment recommendations. Psychotherapy is in fact first line treatment for mild to moderate depression.

The other problem I have with this would be that moderate covers all the ground between barely there and barely hanging on. Some of those folks stand to benefit from pharmacotherapy — and this is more directed towards an audience of PCPs like the OP. There are too few of us and if we don’t open up a little more the NP next door will be happy to get them onto a nice little mixture of vyvanse and Xanax to make the winter blues go away.

 

[DisorderedDoc417]

What makes you say that? Splik is quoting well known, evidence based treatment recommendations. Psychotherapy is in fact first line treatment for mild to moderate depression.

OP also noted above treatment trials #3 (failed two already), so I was assuming we aren’t talking just first-line.

 

[Attending1985]

Please consider not medicating mild to moderate depression. I get so many referrals from primary care that were started on an SSRI years ago for “depression.” Turns out their depression was mental anguish from living with an abusive partner. Antidepressants made them just numb enough to stay now they remain in the marriage and chronically “depressed” now on multiple medications which “aren’t working” I know pcps don’t have the time to deal with this. Send them to someone who does.

 

[clausewitz2]

OP also noted above treatment trials #3 (failed two already), so I was assuming we aren’t talking just first-line.

Except if this is the sort of depression which really ought to have therapy (which is most depression a PCP will see, this is treatment trial #0.

 

[splik]

One of the many problems with conventional psychiatry is the reification of psychiatric diagnoses and their decontextualization from the circumstances of people's existence and their life stories. worst still, most of what gets labeled as depression does not even meet criteria for a depressive illness. so-called antidepressants are not benign interventions, certainly not on a population-based scale: they can cause GI bleeds, cerebral hemorrhages (and RCVS), sexual dysfunction, suicidal ideation, SIADH, dependence and withdrawal, worsen the course of depression, undermine resilience and lead people to see their problems as outside of their control. placebos are in general quite powerful in the management of "depression."

I do not buy the argument that we should be colluding with patients and primary care physicians in search of a pharmaceutical panacea to their psychic woes. 15 minutes is quite a long time actually (longer than many psychiatrists spend with patients) and over the course of a year of multiple appointments is longer still. There are many things one can do in primary care that do not involve summarily dismissing patients with a prescription of a drug which though no more effective than a placebo may certainly be more harmful. In the same way that we should not just dispense benzos, stimulants or opioids to patients on demand, we should not do this with SSRIs. somehow we managed for many years without doing so, and there is no evidence that we are better off as a nation hooked on psychotropic drugs. On the contrary, the chronicity of depression has been enshrined by such practices.

Nor do I buy the argument that it is "easier to take a pill." (but it sure as hell is easier to prescribe a pill; very different). If you look at how poor adherence to medications is and the low number of patients that fill their prescriptions or take their antidepressants daily or for longer than a month, it is a hard proposition. Furthermore, if you are unable to make the changes in your life necessary to relieve your distress, then no amount of pharmaceuticals is going to help.

Our mental states are impacted by the food that we eat, the neighborhoods we live in, the housing that we occupy, the money in the bank, the vices we poison our bodies we, the level of activity we have, the jobs that we work, the friendships that we cultivate, our capacity for love, our early life experiences, the genes that we inherit, the purpose that we have, our connections with others, our physical wellbeing, the level of autonomy and freedom that we have, our opportunity to play.... and many more factors beyond a narrow focus on neurochemistry and the kind of suffering that plagues primary care clinics that is not best conceptualized as "depression" nor treated with drugs.

 

[Attending1985]

One of the many problems with conventional psychiatry is the reification of psychiatric diagnoses and their decontextualization from the circumstances of people's existence and their life stories. worst still, most of what gets labeled as depression does not even meet criteria for a depressive illness. so-called antidepressants are not benign interventions, certainly not on a population-based scale: they can cause GI bleeds, cerebral hemorrhages (and RCVS), sexual dysfunction, suicidal ideation, SIADH, dependence and withdrawal, worsen the course of depression, undermine resilience and lead people to see their problems as outside of their control. placebos are in general quite powerful in the management of "depression."

I do not buy the argument that we should be colluding with patients and primary care physicians in search of a pharmaceutical panacea to their psychic woes. 15 minutes is quite a long time actually (longer than many psychiatrists spend with patients) and over the course of a year of multiple appointments is longer still. There are many things one can do in primary care that do not involve summarily dismissing patients with a prescription of a drug which though no more effective than a placebo may certainly be more harmful. In the same way that we should not just dispense benzos, stimulants or opioids to patients on demand, we should not do this with SSRIs. somehow we managed for many years without doing so, and there is no evidence that we are better off as a nation hooked on psychotropic drugs. On the contrary, the chronicity of depression has been enshrined by such practices.

Nor do I buy the argument that it is "easier to take a pill." (but it sure as hell is easier to prescribe a pill; very different). If you look at how poor adherence to medications is and the low number of patients that fill their prescriptions or take their antidepressants daily or for longer than a month, it is a hard proposition. Furthermore, if you are unable to make the changes in your life necessary to relieve your distress, then no amount of pharmaceuticals is going to help.

Our mental states are impacted by the food that we eat, the neighborhoods we live in, the housing that we occupy, the money in the bank, the vices we poison our bodies we, the level of activity we have, the jobs that we work, the friendships that we cultivate, our capacity for love, our early life experiences, the genes that we inherit, the purpose that we have, our connections with others, our physical wellbeing, the level of autonomy and freedom that we have, our opportunity to play.... and many more factors beyond a narrow focus on neurochemistry and the kind of suffering that plagues primary care clinics that is not best conceptualized as "depression" nor treated with drugs.

This is stated very beautifully and what it comes down to is common sense. I see a complete disregard for common sense in prescribing of psychotropics.

 

[Liquid8]

So, I was curious if anyone would be willing to explain their general approach

Thinking about what I actually do, I don’t think this is an easy question to answer.

When seeing a patient for the first time, one of the first things that I will always do is to confirm or clarify the actual diagnosis even if one is specified on the referral letter. Not all “depression” is actually clinical depression, and could be part of an anxiety, bipolar, substance use or personality disorder which will alter the treatment accordingly.

But let’s say a patient actually does have a major depressive disorder, and they tell me that they’ve tried a couple of antidepressants that didn’t work. While I can accept this at face value, I still need to explore a few other things to inform my management.

For each antidepressant tried, I need to know whether a patient has had an adequate trial or not. I will ask something along the lines of, “What was the highest dose and long did you take it for?” The approach to someone who has taken 60mg of escitalopram for 6 months vs someone on 25mg of sertraline for 2 weeks is going to be markedly different.

I also need to know about any side effects with past medications. Sometimes these actually are due to the medications, but if patients are not taking their treatments consistently they may actually be reporting withdrawal symptoms which may allow past treatments to be reconsidered.

Sometimes patients will tell me they started taking the medication and then it stopped working. While not an exhaustive list, broadly speaking the main reasons that patients might give to explain this happening are:

1) They stopped taking it because they started feeling better
2) The medication spontaneously stopped working
3) There have been new situational stressors

For 1), I’d be more inclined to restart the medication, with psychoeducation about the long term risks regarding ceasing treatment and relapsing. Patients are often concerned about the prospects of having to take something forever and require reassurance that this may not actually be the case.

For 2), I might consider a dose increase or augmentation. A change in drug could also be indicated – which may be cross taper, taper to zero/washout, or straight swap – this is determined by the medications currently being used and considered as well as the patient’s individual risk profile.

For 3), many different approaches could apply.
-If the stressor needs to be actively addressed, attempt to do so. Eg. “I don’t have a pill that will fix the problems you’re having with your partner. Have you thought about seeing a relationship counsellor?”
-If the stressor is expected to pass, it could be reasonable to leave medications as they are and continue to monitor the patient’s mental state.
-The dose could also be increased, either immediately or as a later option if distress remains even after the stressor has passed.
-Some PRN medications could be prescribed in the short term or until the stress passes.
-If something has happened very recently, then some level of distress would be expected, and it may be too early to make any changes.

There may be other biological factors that need to be explored. For the most part our GPs are good at ruling out or managing existing organic conditions, but I always take my own medical history too. As an example, some months ago I saw a patient who had been stable for many years, but started to report a pattern of mood instability. It turned out that just after I last saw them they had their HRT medications altered and the mood swings were triggered when taking the progesterone pills. CC’d their gynaecologist in my letter, they changed the HRT and things went back to the way they used to be.

To make private practice viable, a lot of what will happens treatment wise requires some buy-in from the patient. Part of my job is to discuss the various treatment options with them. I’ll emphasise what course of action I think should occur and the reasons behind this, but ultimately it comes down to their choice. Obviously if they demand something I’m unwilling to provide or isn’t indicated I’ll send them elsewhere, but this is rarely an issue. More typically, I find that patients will be more in favour of either medications or therapy, and there’s usually no issue with going down one pathway before the other with the other option as a backup that can be considered later on.

 

[DisorderedDoc417]

Except if this is the sort of depression which really ought to have therapy (which is most depression a PCP will see, this is treatment trial #0.

I don’t follow. Splik assumed it was the “sort of depression which really ought to have therapy”. Not the OP. I’m just advocating for the OP. I agree with the other sentiments of this post but disagree that a CBT group or therapy is always the right answer for moderate (bordering severe) depression for say, the rural Dakotan farmer who would need to drive 3 hrs one way to receive treatment. That being said, ideally patients are eventually able to receive the best cares possible.

 

[NickNaylor]

I'd be curious to know where the recommendation for psychotherapy for mild/moderate depression comes from. My understanding of the evidence is that either psychotherapy alone or pharmacology are appropriate based on the evidence - ignoring any philosophical disagreements, and I would agree with the idea of using psychotherapy over medications as a first-line treatment.

When I teach the medical students, these are the key points I tell them for non-psychiatric management of depression in, for example, a primary care setting:

- Any evidence of psychosis and/or acute suicidality should prompt referral to a psychiatrist
- Be sure to screen for evidence of substance use to rule-out a substance-induced depressive disorder, particularly alcohol use
- Do a minimal work-up to rule-out medical causes (e.g., hypothyroidism) for depression
- Referral for individual therapy or use of medications is appropriate - see what the patient wants to do

For medication management:

- There is no substantial evidence to support that one antidepressant is better than another - rely on your knowledge of individual drugs and a patient's specific symptoms to choose a treatment
--- For example, avoid bupropion in patients with anxiety/history of eating disorders/seizure disorders but consider it in patients with significant neurovegetative symptoms; consider an SNRI in patients with poorly-controlled neuropathic pain, etc. etc.
- A genuine therapeutic trial requires treatment for at least 4-6 weeks at a moderate dose of an antidepressant
- There is no substantial evidence to support a treatment rationale following failure of an initial medication trial (i.e., switching classes after failure, augmentation, etc.)
- I would recommend referral to a psychiatrist if a patient fails two medication trials as this is typically the point at which treatment-resistance is defined
- If you're just looking for medications that would be useful to have in your armamentarium, I'd suggest being comfortable with one SSRI, one SNRI, and bupropion so that you can have a variety of treatment modalities; I'd arbitrarily suggest escitalopram (generally better tolerated than the other SSRIs) and venlafaxine
- I would not recommend using antipsychotics for any reason for the management of mood disorders as a non-psychiatrist unless you have received some kind of additional psychiatric training as this opens a can of worms that can get you in trouble if you don't know what you're doing

These are very broad guidelines - most of which are evidence-based, some of which are just my recommendation to avoid therapeutic misadventures by non-psychiatrists - but I think can give you enough tools to treat a good number of cases while trying to define boundaries that should prompt referral, largely to protect your own liability.

 

[DisorderedDoc417]

i dont believe i ever said that and do not appreciate having words put in my mouth.

Are we really this sensitive? It was a quote from the person I replied to, in his words, just above mine. Don’t wish to detract from OPs original message any further. Soz.

 

[cbrons]

- I would recommend referral to a psychiatrist if a patient fails two medication trials as this is typically the point at which treatment-resistance is defined

And what if the wait time to see a psychiatrist is 1 year?

 

[NickNaylor]

And what if the wait time to see a psychiatrist is 1 year?

Travel at your own peril. Read the STAR-D summary papers, I guess.

 

[cara susanna]

The problem with nonpharmacological approaches in primary care is that they take time to implement. Explaning sleep hygiene, strategic light/dark exposure, coaching on the use of Calm Breathing, etc., all these things take time which the primary care physician often doesn't have in a 15-minute appointment.

OP how easy is it to find a therapist where you are? Early referral to a therapist (PsyD, PhD, LCSW, MFT, or whatever is available where you are) may be more efficient than waiting for a psychiatry appointment.

Other than that, the main thing I have noticed about non-psychiatrists using SSRIs is that they often don't have a good sense of the time frame required for response. Four weeks is the minimum adequate trial for an SSRI. Side effects, especially GI upset, peak early, before benefit kicks in. It's important to push past that. GI upset and other SE can be minimized by starting low and increasing slowly. If no benefit after 4-6 weeks I usually switch rather than augment. There's no point in continuing something that isn't working, it just results in unnecessary polypharmacy. The Star*D trial showed that augmentation is no more effective than switch in cases of nonresponse to first treatment alternative.

That's why primary care/mental health integration is such a hot field right now. The PCP can give the patient as a warm handoff to mental health, who can work with the patient on behavioral strategies.

 

[NickNaylor]

That's why primary care/mental health integration is such a hot field right now. The PCP can give the patient as a warm handoff to mental health, who can work with the patient on behavioral strategies.

I really hate the term “warm handoff.” Such a circle jerky term.

 

[clozareal]

I'd be curious to know where the recommendation for psychotherapy for mild/moderate depression comes from. My understanding of the evidence is that either psychotherapy alone or pharmacology are appropriate based on the evidence - ignoring any philosophical disagreements, and I would agree with the idea of using psychotherapy over medications as a first-line treatment.

NICE guidelines recommend psychotherapy for mild/moderate depression and not pharmacotherapy for mild, probably because some studies suggest that treatment response for SSRIs don't separate out from placebo at low-moderate severity and even with more severity, the effect size is small at best. The APA guidelines recommend psychotherapy and/or pharmacotherapy for mild/moderate major depressive disorder.

 

[cara susanna]

I really hate the term “warm handoff.” Such a circle jerky term.

Haha, they're obsessed with the term in PCMHI.

 

[NickNaylor]

NICE guidelines recommend psychotherapy for mild/moderate depression and not pharmacotherapy for mild, probably because some studies suggest that treatment response for SSRIs don't separate out from placebo at low-moderate severity and even with more severity, the effect size is small at best. The APA guidelines recommend psychotherapy and/or pharmacotherapy for mild/moderate major depressive disorder.

Awesome, thanks for the reference. I was familiar with the APA guideline but didn't realize the NICE guideline differed.