Treating Depressive Disorders
TIPS TO GET DEPRESSED PATIENTS WELL
A patient's compliance with medication is one of the most crucial factors in effective treatment of depression. However, encouraging patient adherence - especially in the setting of depression where features of the illness mitigate against good adherence - is where the art of medical practice comes into play. Here are a few secrets for helping depressed patients get well.
- Explain the illness. The degree to which patients accept the idea that depression is a biochemical condition is vital to them understanding the role that antidepressant medications can play in improving their mood symptoms . An intelligent, frank and honest discussion about changes in brain chemistry which occur or accompany stressful events can often help patients accept that they need to take antidepressant medication to restore physiological imbalances.
- Identify target symptoms. By identifying target symptoms as tangible markers of a patient's progress, physicians and their patients can better monitor progress and, as identified symptoms improve, confidence in treatment should be enhanced. The most helpful symptoms to target are sleep disturbances, appetite changes, energy levels and anxiety, as these symptoms are highly prevalent in depression and are usually the first to improve, followed by an improvement in mood.
- Explain why the medication is needed. This may involve a reiteration of the physical nature of depression, along with what symptoms are likely to improve first, when and how. Because there is a tendency for patients to focus on side effects of the medication, physicians need to emphasize that the benefits of taking the medication come as part of a continuum of treatment for depression, and that therapeutic effects are an expected part of that continuum provided patients persevere.
- Factor in features of depression. Certain clinical features of depression influence compliance and treatment outcome. These include the severity and duration of illness; chronicity has been implicated in poor compliance. Comorbid conditions should also be taken into account when planning a treatment strategy for patients. If a patient has a comorbid substance abuse problem, for example, both disorders should be treated simultaneously unless it is felt that the depressed mood is solely due to the substance misuse. Exaggerated guilt in patients may also make them feel unworthy of treatment; personality features including suspiciousness, lack of acceptance of the illness and fear of stigmatization need to be addressed at the outset to enhance compliance.
- Establish a therapeutic alliance. The first few weeks of treating depression are critical, as this is when the therapeutic alliance is established between physician and patient and the basis for ongoing treatment is set. During these initial weeks, anxiety and sleep disturbances are common problems associated not only with depression but also initiation of treatment. Physicians thus need to educate the patient about the illness and its consequences, and set expectations for treatment in a supportive way. These strategies not only help cement the therapeutic alliance, but enhance compliance especially through the initial and often difficult few weeks of treatment. Once the therapeutic alliance has been established, physicians and patients can work together through problems and conflicts in a collaborative way that should enhance adherence to therapy and optimize the likelihood of a successful outcome.
- Be empathetic. Physicians have a responsibility not only to treat an illness but to support their patient, and to convey that support through empathy and understanding of their patients' experience. Once patients feel they are understood, they are much more likely to trust the physician and his or her judgement- and hence, more likely to persist with treatment, even when benefits are not immediately apparent.
- Convey hope and optimism. The power of hope in the recovery of the patient should not be underestimated. Depressed patients are by definition unable to be optimistic or hopeful, and they may attribute the delayed onset of antidepressant action as some fault of their own and abandon treatment as yet another futile exercise. Given the effectiveness of current antidepressant medications, physicians can honestly convey their confidence in the treatment plan to patients, and reassure them that they are extremely likely to get better, provided they comply with their treatment plan.
- Disclose the most common side effects and when to expect them. Patients should be reassured that most side effects are mild and transient; that they usually occur when the medication is being started or when the dose is increased, and that they generally resolve with time. Some side effects occur early on in treatment (as soon as the first pill is taken); others, such as sexual dysfunction, may show up early but not become an issue until patients resume interest in sexual activity. The initial choice of antidepressant thus must take into account possible short as well as long-term side effects to ensure patient compliance.
- Explore patient resistance to medications. By exploring often learned attitudes related to illness and the sick role, physicians have an opportunity to address these attitudes. A change in the patient's thinking about medications may well enhance compliance. As importantly, patients who are unhappy with their response to antidepressants are more likely to stop taking the medications and experience discontinuation symptoms as a consequence. Physicians therefore need to make sure that patients understand that they are unlikely to notice any change in symptoms until the 2nd to 4th week on treatment - at which point, sleep, appetite and energy should improve. Mood may take up to 8 weeks to improve significantly. If patients expect early results, they are more likely to stop taking the medication due to a perceived lack of efficacy. They also need to be reminded to take the medication every day, as prescribed, even after they begin to feel better, and to check with their doctor before they stop taking the medication. If side effects are troublesome, there are many other antidepressants from which to choose and a better pharmacological fit may be found.
- Discuss complementary therapies: Many patients are greatly interested in complementary therapies (eg. St. John's Wort) for treatment of depression. A frank discussion of complementary therapies shows patients that the physician is both knowledgeable and open to the idea of alternative treatments and that the chosen medication was carefully considered against other potential alternatives. A discussion of alternative approaches also allows patients to feel as if they are actively involved in their treatment. (Link to interview with Dr Jacques Bradwejn)
- Follow the patient closely. Close follow-up in the initial phase of antidepressant therapy is essential to monitor response as well as adverse effects. Patients who are seen only monthly on initiation of treatment may develop side effects and stop taking the medication between visits, which could precipitate a relapse. The uncertainty that the illness and its course can have in the early part of treatment necessitates regular, consistent visits in order to ensure successful resolution of symptoms.
Section III: "Pharmacotherapy"
Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults (2009).