Management of depression in the outpatient office

Major depression

Major depression is a common, disabling condition seen frequently in primary care practices. Non-psychiatrist ambulatory providers are increasingly responsible for diagnosing, and primarily managing patients suffering from major depressive disorder (MDD). The goal of this review is to help primary care providers to understand the natural history of MDD, identify practical tools for screening, and a thoughtful approach to management. Clinically challenging topics like co-morbid conditions, treatment resistant depression and pharmacotherapy selection with consideration to side effects and medication interactions, are also covered.

The increasing frequency of mania and bipolar disorder: causes and potential negative impacts

The frequency of mania has not changed during the last century even with the development of new diagnostic criteria sets. More specifically, from the mid-1970s to 2000, the rate of mania (variably labeled major affective disorder-bipolar disorder and bipolar I disorder) was consistently identified in US and international studies as ranging from 0.4% to 1.6%. By the late 1990s to the 2000s, the prevalence reported by some researchers for bipolar disorders (I and II and others) was in the 5% to 7% and higher ranges. The purpose of this paper was to review explanations for this change and the potentially negative impacts on the field.

Continuing Medical Education: Sexual Medicine Education: Review and Commentary (CME)

INTRODUCTION

Sexual medicine education is an important and fundamental topic not adequately represented in most undergraduate and residency training programs.

AIM

The purpose of this article is to better enable the participant to understand the importance of sexual medicine education, and to review existing models and innovations in undergraduate and graduate medical education. This activity is designed for the practicing physician. Methods. A literature review of the topic was performed.

MAIN OUTCOME MEASURE

Current state of, and new developments in, sexual medicine education.

RESULTS

In all countries, medical students, house staff, and practicing physicians currently receive variable, nonstandardized, or inadequate training in sexual history taking and sexual medicine assessment and treatment. There remain significant physician-patient barriers to discussing sexual issues; and patients feel that their physicians are reluctant, disinterested, or unskilled in sexual problem management. There is a knowledge gap between developments in sexual medicine and the clinical skills of practicing physicians.

CONCLUSIONS

The challenge is to create uniform, widely available programs that provide practicing physicians across specialties with the needed skills to meet modern patients' needs in sexual medicine healthcare delivery.

Obstetrician-gynecologists' decision making about the diagnosis of major depressive disorder and premenstrual dysphoric disorder

Major depressive disorder (MDD) is underdiagnosed and undertreated in ambulatory care settings including gynecologic practices. Far less is known about the diagnosis of Premenstrual Dysphoric Disorder (PMDD). Three hundred and thirty-five gynecologists responded to mailed questionnaires that used descriptive scenarios as analogues to clinical cases. Questionnaire recipients were randomly selected to receive either a MDD or PMDD version of the questionnaire. Respondents were less accurate when diagnosing MDD cases (48% accuracy; p = 0.526), than PMDD cases (80% accuracy; p < 0.001), but were significantly more confident about their probability ratings of MDD cases, t = 2.57, p < 0.02. Qualitative analysis suggested that less accurate MDD respondents did not prioritize case data according to DSM-IV criteria, whereas almost all PMDD respondents made use of valid reasoning strategies. Respondents did not take base rates into account when deciding about the probability of either affective disorder. Results imply that gynecologists employ cognitive strategies that result in accurate diagnostic judgments about PMDD, but overconfidence, lack of attention to DSM-IV criteria and base rate neglect could hinder clinical decisions about MDD, and may contribute to underdiagnosis of depression.

Considerations in the management of the patient with comorbid depression and anxiety

PURPOSE

To provide clinicians with guidelines for the assessment, evaluation, diagnosis, and management of comorbid depression and anxiety in the primary care setting.

DATA SOURCES

Research-based articles in the medical and psychiatric literature, literature reviews by experts in the field, and DSM-IV-TR.

CONCLUSIONS

Comorbid anxiety and depression occurs at a high rate in primary care, and is costly to both the individual and to society. These patients most often present in primary care settings, have more severe symptoms, and require more health care resources. The presentation of depression and anxiety together pose complicated diagnostic and treatment challenges, leading to inadequate diagnosis and treatment resulting in unnecessary patient distress and increased utilization of health care services.

IMPLICATIONS FOR PRACTICE

This article is a review of comorbid depression and anxiety with a focus upon societal and patient significance and impact, under recognition and under treatment, diagnostic challenges, medical comorbidity, treatment considerations, and educational strategies. Effective assessment, evaluation, diagnosis and treatment can lead to better treatment outcomes and improved quality of life in primary care patients.

Depression treatment in rural California: preliminary survey of nonpsychiatric physicians

Depressive disorders have been recognized as disabling conditions of public health proportions. However, in areas underserved by mental health professionals, the treatment of depressed patients becomes challenging. Furthermore, patients living in rural areas and communities underserved by health professionals are at risk for high levels of depressive symptoms and low access to care. Physicians (N = 58) of multiple nonpsychiatric specialties in Imperial County, a rural underserved area in California, were surveyed to ascertain their preferred strategies in the management of depressed patients. More than half (57%) of the respondents preferred to either refer patients to a mental health specialist (p < .01) as the only strategy, or in combination with counseling, prescribing medication, or both. The most commonly reported form of counseling was of a supportive nature. The most commonly prescribed drugs were selective serotonin reuptake inhibitors (in order of frequency:fluoxetine, sertraline, and paroxetine). Tricyclic antidepressants and benzodiazepines were identified as first-line drugs by some pediatricians and surgeons. The results of this study support the need for enhanced postgraduate training in the treatment of depression for nonpsychiatric physicians, and greater exposure of psychiatric residents to rural psychiatry.

The lived experience of using Watson's actual caring occasion to treat depressed women

Each year, 19 million clients are treated for depressive episodes lasting 6 to 12 months. With depression's economic costs between 16 to 43 billion dollars annually, managed care has reduced clinician time, currently averaging 25 minutes per visit. The purpose of this phenomenological study is to describe the essential structure of the lived experience of depressed women who enter therapy and experience Watson's actual caring occasion (ACO) within the transpersonal caring relationship (TCR). A purposive sample of 11 depressed women related their subjective experiences in therapy over 6 months. Spiegelberg's phenomenological method was used for data analysis of 110 pages of therapist's notes transcribed verbatim. Five essential themes emerged from data analysis. All participants stated Watson's ACO caused them to persist in treatment and adopt health-seeking behaviors. This finding supports the expense of appropriate clinician time for holistic healing in the TCR.

Depression in the patient with rheumatologic disease

Depression is commonly seen in patients with chronic disease, including rheumatologic disease. Because of ongoing contact with their patients, rheumatologists are uniquely poised to recognize depressive disorders and formulate a treatment plan. Recent advances in pharmacotherapy have simplified management and increased the likelihood of successful treatment. Through heightened awareness, rheumatologists can feel more comfortable in diagnosing and initiating therapy for depression.