Depression in the Primary Care Setting

Published - Written by Carla Rothaus

What factors should be considered when selecting which antidepressant to prescribe for moderate depression?

Depression is a clinically significant and growing public health issue. In 2015, depressive disorders were estimated to be the third leading cause of disability worldwide. Primary care providers are important in recognizing and managing depression. An estimated 60% of mental health care delivery occurs in the primary care setting, and 79% of antidepressant prescriptions are written by providers who are not mental health care providers. Read the NEJM Clinical Practice article here.

Clinical Pearls

Q: What are some of the risk factors for depression?

A: The onset of major depressive disorder is bimodal; most patients present in their twenties, and a second peak occurs in the fifties. Women are twice as likely to have depression as men. Other risk factors for the development of major depressive disorder include being divorced or separated, previous episodes of depression, elevated levels of stress, a history of trauma, and a history of major depressive disorder in first-degree relatives. Universal screening for depression in all adult patients in the primary care setting, including pregnant and postpartum women, has been recommended by the U.S. Preventive Services Task Force.

Q: What are some of the medical conditions that have been associated with depressive symptoms?

A: Multiple medical conditions have been associated with depressive symptoms; these conditions include anemia, hypothyroidism, seizures, Parkinson’s disease, sleep apnea, deficiencies of vitamins such as B12 and folate, and infectious diseases such as human immunodeficiency virus (HIV) infection, syphilis, and Lyme disease. In some cases, treatment of these underlying conditions may decrease or resolve depressive symptoms.

Morning Report Questions

Q: What factors should be considered when selecting which antidepressant to prescribe for moderate depression?

A: For mild depression, initial preference should be given to psychotherapy and symptom monitoring, with pharmacotherapy reserved for cases of insufficient improvement. Psychotherapy, pharmacotherapy, or both should be considered for moderate depression (consultation with a psychiatrist should be obtained for a patient with severe depression and urgently in any patient with psychotic symptoms or suicidal thoughts and behavior). The selection of an antidepressant is guided by adverse-effect profiles as well as by the patient’s coexisting psychiatric disorders, specific symptoms, and treatment history. A goal should be to minimize adverse effects, particularly those that might exacerbate existing symptoms or other medical conditions. For instance, drugs commonly associated with increased sedation (e.g., mirtazapine and paroxetine) are not administered during the day in patients with fatigue; conversely, for patients with difficulty sleeping, these sedating drugs may be prescribed at bedtime to promote sleep. Patients with coexisting anxiety are often treated with selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors, whereas bupropion and levomilnacipran are generally not used.

Q: What is the recommended duration of maintenance antidepressant therapy?

A: If the initial trial does not yield substantive improvement, switching to another first-line antidepressant (of the same or a different class) is appropriate. Psychotherapy should also be considered, since the combination of drug therapy and psychotherapy has been shown to be more effective than drug therapy alone. If partial improvement is noted at the maximally tolerated dose, adding an antidepressant of a different class or targeting residual symptoms with other treatments may be an appropriate next step. Psychiatric consultation is recommended if combined therapy or use of a treatment option other than first-line therapy is being considered. Once remission is achieved, maintenance antidepressant treatment to decrease the risk of relapse should generally be continued for at least 6 months. For persons with a high risk of relapse (e.g., two or more past episodes, residual symptoms, or a history of prolonged or severe symptoms), maintenance treatment should be considered for 2 years or more. Recurrence of symptoms is common after an index episode; longitudinal studies have shown recurrence rates of 26% within 1 year and 76% within 10 years.

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