Treatment-resistant Depression In Primary Care 

Most patients with depressive illnesses present to their GPs; between one in three and one in five patients will have a depressive illness.  60 – 70% of sufferers will respond positively to antidepressant medication, though some will not enjoy full remission of symptoms. Even though many sufferers remain undiagnosed, often presenting with other physical conditions, 2.9m people are diagnosed with depression annually and around 17% of the population will suffer from major depression at some point in their lives. Treating non-responders is one of the biggest challenges facing GPs.
Dr. Tim Cantopher discusses treatment-resistant depression in primary care.

“First, analyse why this patient’s depressive illness hasn’t responded to first line treatment,” explains  
Dr. Cantopher. “It’s best to ask a few key questions before changing antidepressants.” 

  • Does the patient have a depressive illness or is he just unhappy? Unhappiness doesn’t respond to antidepressants. 
  • If the patient has a depressive illness, is he or she taking his/her treatment? If not, why not? The most common reasons patients cite are: I prefer to do it on my own, without pills; antidepressants aren’t natural; antidepressants are addictive; antidepressants give you a false high and change your personality; Prozac can make you violent; I tried an antidepressant for a few days and it made me feel worse; I tried one for several weeks and it didn’t work; I looked at the patient information leaflet, saw the side effects and they scared me so much that I decided not to take the pills. Discover the patient’s misconceptions and then explain that his fears are not viable. Dispelling these notions is often enough to get patients to comply with treatment 
  • Does the dosage need to be increased? 
  • Is the patient not compliant because of unacceptable side effects? Is it worth changing to an antidepressant with a different side effect profile? 
  • Has the patient failed to accept that he is ill and is he expending energy in inappropriate ways? Patients with double pneumonia rest and take their drugs; patients with depression should do the same – soldiering on is counter-productive 
  • Do other family members thwart recovery by making excessive demands on the patient? If so, a brief explanation of the condition to family members can make a difference

“Antidepressants and rest can work wonders, but if nothing else in his life changes, the patient either won’t make a full recovery or, if he does, it’s just a matter of time before he becomes ill again. If a patient doesn’t change the way he lives – if he neglects his own needs and repeatedly becomes exhausted and ill – he probably needs some form of psychotherapy to achieve full remission of symptoms,” 
Dr. Cantopher.

  • Short-term focal exploratory psychotherapy helps patients examine the issues underpinning their illnesses and how to tackle them. 
  • Cognitive behaviour therapy focuses on negative self-defeating thought patterns, helping patients to change their thinking styles and the 
  • way they operate. 
  • Supportive counselling helps build patients’ defences against the problems surrounding them. 

    All of the above can be organised at a primary care level.

    Primary care treatment options If an antidepressant isn’t working but is well tolerated, try a higher dose; following recent guidelines, paroxetine should not be used above 20mg per day for depression. Citalopram should not now be prescribed at above 40mg daily owing to reports of occasional arrhythmias at higher doses. If there is no response within four to six weeks, then the antidepressant will probably not work; if there is a partial response, it is worth waiting another four to six weeks to see whether an adequate response will follow. “It is worth changing nonresponders to a different antidepressant,” explains Dr. Cantopher. “Most authorities suggest that switching to an antidepressant with a different mode of action is often associated with a better response, so if an SSRI isn’t working, try a noradrenalin drug like reboxetine or a drug acting on both serotonin and noradrenalin systems like venlafaxine. Because SSRI’s are structurally diverse, switching from one SSRI to another might also be successful. Whenever a drug is switched it is important to monitor the patient for drug interactions or other adverse effects, particularly if the half-life of the first agent is quite long (e.g., fluoxetine). How quickly to withdraw the first drug and to substitute the second is always a difficult judgment, but it’s usually best over two or three weeks to minimise side effects and get the new agent started as soon as possible. It is also important to warn the patient that the transition period can be difficult through the quadruple whammy. A patient may get some withdrawal symptoms from the first antidepressant, lose its therapeutic action, have maximal side effects from the new drug and wait some time before this drug works. Patients will usually tolerate this if they are warned of the difficulties and reassured that they are 
    likely to disappear.” Combining two or more antidepressants isn’t recommended in primary care: this can obscure monotherapy evaluation and lead to significant adverse effects or drug-drug interactions. 

    When to refer 

    Most patients will respond to antidepressant treatment and appropriate counselling in a primary care setting. Those who do not are worth referring to a consultant psychiatrist. “Patients with complex needs or who suffer from a dual diagnosis such as substance misuse, eating 
    disorder, an anxiety disorder or any other co-existing psychiatric condition are best referred to a psychiatrist,” says Dr. Cantopher.