Major depression diagnosis and treatment in clinical practice

¶ … Depression

Diagnosis and Treatment -- Research Findings and Information

Diagnosis

Major depression is diagnosed via clinical means. It is based on interviews and examination of the mental status of the patient. Evidence points to the fact that interviews compare well with other diagnostic procedures used in medical practice including radiologic examination and lab tests. The method of diagnosis applied in DSM-IV (Table 1) is the commonly accepted approach. Major depression is observed through syndromes. The final diagnosis is based on the patient's physical condition and medical history. In the process of diagnosis, it is critical to consider other possible problems including psychiatric problems such as obsessive compulsive disorder, bulimia nervosa, dementia and panic disorder. There should also be an observation of the general medical conditions, abuse of substances disorder so as to follow relevant investigations in the diagnostic processes (Goldman, Nielsen, & Champion, 1999).

There are tools available to physicians. These tools can assist the practitioners to foretell people likely to experience major depression. Like other screening tools, these tools seem general and do not focus on depression specifically. Scholars and specialists propose that screening be applied when the practitioner has good reason to suspect the occurrence of the same. Such suspicion is usually triggered by some specific symptom that points to the possibility of depression. These symptoms include subjective distress that is beyond the norm, some impaired functioning or another psychiatric problem. There is need for physicians to appreciate screening results with a keen eye and recognize the need for further tests to eliminate any doubt. There is no preventive guide that encourages screening in patients that do not show any symptoms of the depressive disorder (U.S. Preventive Services Task Force, 1996). The primary version for care of depression patients DSM-IV gives abbreviated guidance of the DSM-IV criteria for diagnosis of mental disorders in patients commonly witnessed in primary care centers. It comes with dynamics influenced by the patients to enable the practitioner to move from the complaint of the patient to a precise diagnosis of the problem. There is now a pediatric version of DSM-IV that has been developed by the American Academy of Pediatrics. WHO has also developed a version for the primary care based on the international classification of diseases that deal with mental problems (ICD-10). This resource contains information cards on the common complaints raised by patients, the diagnoses and the management of 24 common disorders of psychiatric nature (B, D, & J, 1995). Some aspects of DSM may cause problems in a conventional medical setting. Some symptoms are somatic on nature. Even though the criteria for diagnosis gives equal consideration to all the nine syndromes many clinicians fail to recognize depression as forming part of the pivotal diagnosis of the main complaint that the patient comes with; unless the patient clearly shows signs of sadness or that the complaint is of diasphoric nature. It is also worth noting that it is normal for patients to tend to emphasize physical symptoms because these tend to be more disturbing to the patient. Patients are usually less enthusiastic about providing information on their mental status or emotional distress because they mistakenly think that the practitioner will be interested in the symptoms that they provide. It is often hard to determine whether a given symptom is caused by depression or by a different medical problem.

Treatment scientific advances including the evolutions in the practice environment shape the treatment of depression in recent times. The United States has seen the introduction of several new antidepressants including (fluoxetine (Prozac), nefazodone (Serzone), paroxitene (Paxil), venlafaxine (Effexor), fluvoxamine (Lu-vox), and citalopram (Celexa) sertraline (Zoloft), bupropion (Wellbutrin), mirtazapine (Remeron). The drugs are different in terms of structure and pharmacological nature as compared to tricyclic and monoamine oxidase inhibiting agents. These medications inhibit a benign side effect, a simple dosing strategy, better adherence to prescription and a much lower death risk in situations of overdose as compared to older medications. Given the advantages, these medications have been widely applied in the field. These new drugs have been noted to exhibit a delay in the full therapeutic recourse. It normally takes several weeks for them to show their effect. When looked at against the background of older drugs, they manifest a shadowy relation between drug levels in serum and the response to the treatment. Some of them hold potential risk of presenting drug interaction (Masand, Chengappa, & Edwards, 1998). There have been several attempts in the testing of the available psychotherapies and their effectiveness. Behavioral, cognitive and interpersonal psychotherapy that are structured and limited in terms of time have been demonstrated to be equal in the levels of efficacy to anti-depressant medications for moderate and mild psychotic and non-bipolar major depression; this is the type that has been commonly seen in most medical environments. These medications are generally a welcome alternative to the patients that are averse or intolerant to antidepressants. They are also attractive to the patients that prefer to use psychotherapy, pregnant women and nursing mothers. It is not clear whether the effect of combining psychotherapy and pharmacotherapy is more successful than when the options are applied independently. The role of other psychotherapeutic options is also largely unknown (Goldman, Nielsen, & Champion, 1999).

Depression is increasingly appreciated as a chronic illness. At least half of those that experience major depression episodes without another medical condition occurring at the same time will proceed to experience another one. After a number of episodes, the risk of reoccurrence increases to 90%. Although a lot of patients make a complete recovery from specific episodes with the use of treatment or without it, approximately a fifth to a third of them have their symptoms persist residually or functioning impairment or both issues. There is an increased interest in the use of medications in prophylactic fashion, especially after the patient has undergone a number of episodes, i.e. after stopping psychotherapy or when it is offered at random or far between. Most of the information regarding the prevalence of infection, the cause and the treatment efficacy levels was reexamined, synthesized and published as a set of guidelines for treatment on depression focused on primary care centers by the Agency for Health Care Policy and Research (AHCPR) (Agency for Health Care Policy and Research, 1993)

Possible approaches to the suggested issue

Major depression is common and treatable. Many patients benefit from pharmacological treatments since there is hardly any variation in the level of effectiveness of antidepressants. The choice of medication should be based on the patient's symptoms and characteristics, their safety and the expected side effects. A lot of patients respond well to the treatment but a lot of them do not have complete relief of symptoms. Augmentation or changing medication can be useful to some non-responders. It should be noted that antidepressants have the potential for producing harmful side effects. Some of them are known for drug-drug interactions. Suicide is always a possibility in depression cases. It should also be noted that such risk is never always reduced by the use of antidepressants. There is need for a close follow up when starting therapy and adjusting dosage (Adams, Miller, & Zylstra, 2008).

Non-pharmacological

Psychotherapies

Psychotherapy or counseling has the potential to assist people in depression. CBT (cognitive-behavioral therapy) is a good example of evidence based approach that can handle depression. Others are problem solving therapy and Interpersonal Therapy. There is a lot of information on NIMH (titled "Depression: What You Need to Know") website.

Brain Stimulation Therapies

Based on new research, if medication does not reduce symptoms of depression, practitioners may want to try out electroconvulsive therapy (ECT).

It is known to provide relief to severe depression cases

It is a good option if it is an emergency case or when other options and medications are not a safe option.

ECT has lately been applied on outpatient cases and is carried out over a period of time with a frequency of about three times each week for between two to four weeks.

Most of the side effects of ECT are temporary; although loss of memory is one that lasts a little longer. This is especially true around the time of the treatment course.

ECT has become increasingly safe in the recent day. You only need to discuss with your doctor to check if you can also benefit from it.

The application of ECT requires that the patient is put under some anesthesia and relaxant. However, the procedure is not painful. The patient usually becomes alert within an hour of application of ECT. There are other brain stimulation treatments for depression. They include repetitive transcranial magnetic stimulation, and VNS (Vagus Nerve Stimulation). There are other forms of brain stimulation that are still being studied (NIMH, 2016).

Pharmacological treatment

Medications

Antidepressants may improve the way your brain makes use of certain chemicals that influence mood. The journey towards finding an antidepressant that is suitable for your body is a long and winding process. Usually, medications that have either helped you in the past or even a close member of the family may be used. These drugs take effect over a long period; usually two to four weeks. The drugs help the body to change certain aspects including enhancing better sleep, concentration issues and appetite. These come before the mood improves. Don't stop prescribed medicine before you consult your doctor. The doctor will usually help you to wean off the antidepressants. Otherwise, you might experience withdrawal symptoms. One half of depression patients partially respond to medicine. Depression symptoms of residual nature persist in most of them. A third of depression patients respond to a single antidepressant after three months of treatment. A half of those who respond to treatment only show such response after a period of over 8 weeks. You need up to 4 for treatment in order to achieve a single responder for tricyclic. It takes from 5 to 11 for the TCA and between 21 to 94 for SSRIs (selective serotonin reuptake inhibitors) before the treatment can be stopped. Cultural and clinical/medical factors are also known to influence the response to treatment. Some common predictors include the level of education, high income, insurance, high physical and mental functioning, and a relatively shorter depression period (Adams, Miller, & Zylstra, 2008).

There is Need to Defend the choice of the treatment option

There are many options for treating major depression. Medication and psychotherapy can ease symptoms of depression. There is empirical support for brief psychotherapy to relieve major depression too. It has been noted that pharmacotherapy alone is not effective in children and in adolescents. It has been observed that in all cases a combination of psychotherapy and medication provides a fast and sustained response. Combination therapy has been lauded for its success in improving the quality of life of patients, better compliance and in cases of prolonged treatment. Pharmacotherapy is recommended. CBT is the choice here.

Cognitive-behavioral therapy (CBT)

CBT is a directed and timed sensitive procedure. It usually takes between ten to twenty treatment sessions. Cognitive therapy happens to be the more widely used form of CBT for treating depression. It is based on the premise that patients with depression show the cognitive triad of depression. This includes viewing themselves negatively, lack of hope and pessimism about the world. patients such as these are also believed to harbor cognitive distortions that cultivate the negative feelings and impressions of the world around them. It has been suggested that problematic schemas are the source of negative thoughts and cognitive distortions. These schemas influence how information is interpreted and used. CBT application for depression involves restructuring of cognitive processes aimed at altering negative automatic thoughts and correcting maladaptive schemas (Halverson, 2016).

Create a referral plan and follow up if need be

Psychotherapy is to be done on outpatients with 60-minute session plans per week. There is a wide range and variation in its application but psychotherapy is usually limited in time, i.e. 16 sessions.