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Outpatient Management of Depression 4 - What to Say to the Depressed Patient and How to Say It

As part of the treatment planning, the clinician must decide whether to treat the patient as an outpatient, in the hospital, or refer to a psychiatrist. Hospitalization is generally based on the following considerations: Is the patient at high risk for suicide?

• Is the patient psychotic?
• Is the patient so functionally impaired that s/he cannot ensure that basic needs will be met?

How to Assess the Suicide Risk

The prediction of suicide risk is imperfect at best, although often obvious in hindsight. There are risk factors that can be useful when assessing the patient's potential for suicide (Table 4.1).

Previous suicide attempts bear special comment since they are counterintuitive. Patients can be divided into those who have a history of no or one previous suicide attempt and those with multiple suicide attempts (more than 4 previous attempts). The latter history is more suggestive of a personality disorder rather than major depression. Such patients are more at risk for future attempts than for suicide completion. While it may initially seem counterintuitive, the absence of a history of previous attempts does not substantially diminish the risk of suicide completion. The reason is that the majority of patients who commit suicide do so on their first or second attempt. When the clinician is confronted with a moderate to more severe, full depressive syndrome in a previously nonaffected, middle-age-to-older patient, then suicide risk must be carefully considered regardless of whether s/he has made a previous attempt. This issue is particularly important in the patient who has:

• A positive family history for suicide
• Prominent feelings of hopelessness and/or guilt.

How to Inquire About Suicidal Ideation

Some clinicians are uncomfortable about inquiring about suicidal ideation. They believe that it will anger the patient. Others believe that it may "plant the seed." A few may not want to know the answer.

The first two concerns can be easily dispelled. Most patients will be relieved and thankful that the clinician was sufficiently concerned to inquire, assuming it is done in a tactful manner as discussed below. There is also no evidence that such questioning prompts patients to commit suicide. Instead, it uncovers patients at risk so that appropriate preventive steps can be taken.

At the time the patient describes a depressive episode, the clinician can empathize with the patient and simultaneously begin exploring for the presence of suicidal ideation by saying:

"You sound as if you have been feeling pretty miserable. Has life ever seemed not worth living?"

In response, most patients will spontaneously state they have or have not had such thoughts. They often will go on to say that they would never commit suicide for a variety of reasons (eg, religious beliefs, effect on family and friends). If the patient acknowledges feeling that s/he would be better off dead, but does not explicitly state how actively s/he has contemplated suicide, the clinician can follow-up by asking:

"So, you have felt that life was not worth living. Have you ever thought about acting on those feelings?"

If the patient acknowledges that s/he has, the clinician should then explore how far such thinking has gone:

• Does s/he have a plan?
• If so, what is it?
• Has s/he acted on it?
• If so, how recently?

If the patient has made a plan, has the means, or has recently acted on it, then hospitalization is obviously needed. If the patient is in a gray area, the clinician must decide how impulsive the patient is and whether a good faith agreement can be made to contact the clinician or come to a care facility if suicidal ideation becomes intrusive, persistent, and compelling.

Is the Patient Psychotic?

A small percentage of patients with major depression in the primary-care setting will have a mood-congruent hallucination or delusion. Examples include: the patient hears a voice stating that s/he is evil and deserves to die, or the patient believes that s/he has contracted a serious illness as a punishment for an earlier imaged sin or transgression. Such patients warrant hospitalization because of the likelihood of acting on the psychosis.

Is the Episode So Severe That Hospitalization Is Necessary?

This issue requires the clinician to make several assessments:

• How much functional impairment has the depressive episode caused?
• What are the functional demands on the patient at work and at home?
• Are there support systems that can help offset any imbalance between the patient's functional status and the functional demands on the patient?

Based on the answers to the questions, the clinician can determine whether the patient needs a release from work and needs further functional support, up to and including hospitalization.

Most patients with major depression seen in a primary-care setting can be appropriately treated on an outpatient basis. Nonetheless, the decision of where to treat and whether to seek a consult or refer must be made with careful deliberation.

Initiating Outpatient Therapy

The first step is educational and empathic counseling. Patients with any illness present with questions outlined in Table 4.2. Added to these universal questions are the following issues commonly encountered in patients with major depression:

• They feel guilty or responsible for their illness
• In searching for a reason, they often attribute their illness to outside factors such as "stresses" on the job or at home
• Job or home-life problems may be a result rather than a cause of their illness.

The clinician and staff need to address these issues empathically and efficiently. That can be done by anticipating common issues and providing standard educational information without having to wait for the patient to ask. The common questions/issues that patients have include:

• What Do I Have?

You have major depression. Like many illnesses, we do not completely know what causes it. We do know that it runs in families like other illnesses such as diabetes and hypertension. That fact and others lead us to believe that major depression is due to biochemical changes in brain function, sometimes described as a "chemical imbalance."

Although many patients who are depressed think they caused it or that it is a sign of personal weakness, there is no evidence to support this belief. It is no more true for major depression than for diabetes or hypertension.

• Will I Feel Better?

Yes. While we do not know precisely what causes major depression, we do have a number of effective treatments for it. With such treatment, you have an excellent chance of being over this episode in a matter of weeks. Without such treatment, you might get better spontaneously, but it could take months or even years. Unfortunately, antidepressants do not work for depressive episodes as aspirins do for headaches. It may take 2 to 4 weeks of treatment before you start to notice substantial improvement. Nonetheless, you will begin to feel better.

You can think of response to antidepressants like the treatment of a sore throat with antibiotics. While the antibiotic begins to kill the bacteria within hours of starting it, there is a period before you notice the improvement. In the case of antibiotics, the delay is a couple of days. With antidepressants, it may be a couple of weeks. Bear with it because you will begin to feel better.

In the case of both antibiotics and antidepressants, you should continue treatment for a period even after you feel better. We generally advise you to keep taking an antibiotic for 5 to 7 days after you feel better to ensure complete eradication of the bacteria and thus reduce the likelihood of a recurrence of the infection. We advise that you continue taking an antidepressant for 4 to 5 more months after you feel better because that is the interval during which you are at risk for a relapse. We will discuss this issue further after you are feeling better. The point now is to get you well.

• What Will It Take to Feel Better?

We use antidepressant medications to shorten the time necessary to get over an episode. Most patients will experience either significant improvement or a full remission from their episode within a couple of weeks of starting an antidepressant. In some individuals, full improvement can take 6 to 8 weeks. Remember that these medications take time to work and do not be discouraged by the fact that you do not feel immediate relief. For you to respond, you need to take the medication regularly as prescribed.

Some patients may worry that others might think that taking antidepressant medication is a sign of "weakness." People would never accuse a patient with diabetes of being weak for taking insulin. You are feeling badly enough and you should not be berating yourself for your illness. Instead, let us work together to get you well.

Some patients wonder whether medications are the total answer. They virtually never are for any significant illness, whether it is major depression or hypertension. At a minimum, you need to know about the illness so that you can optimally deal with it.

Many patients with major depression will respond fully to supportive counseling plus medications Others may need more formal counseling called psychotherapy. Generally, that decision is an individual one, between the clinician and the patient.

• What Should I Do?

There are several steps you can take to help in your treatment. It is important to learn about your condition so that you will know what to expect, particularly during the initial period of treatment. Do not blame yourself for your major depression. Realize that you did not ask to suffer from it. Your self-esteem has likely been shaken as would be true for anyone who has had such an episode. Give yourself a reprieve from negative thinking for now. Take your medication as prescribed. Get plenty of rest, stay physically active, eat regularly, and keep socially involved.

• What Should I Not Do?

Do not drink alcohol when suffering from major depression. Alcohol causes similar changes in brain chemistry as occurs during a depressive episode. Many patients with major depression attempt to self-medicate by drinking alcohol to either help themselves sleep or to "calm their nerves." Don't do it. While it may initially help you to fall asleep, its sedative effect wears off quickly causing early morning awakening. For the same reason, do not use illicit drugs, or other sedative agents or stimulants.

Do not make any major life decisions while moderately or more severely depressed. What may seem like a mountain of a problem when you are feeling poorly may seem much more manageable when you are feeling better.

• Will It Happen Again?

Although the focus now should be on getting well, you may be concerned about the risk of future episodes. The risk is primarily dependent on three factors: the duration of the current episode, the number of previous episodes, and your family history of major depression.

The likelihood of having recurrent episodes increases if your first episode has lasted longer than 2 years, which is one compelling reason to treat it aggressively now. Your risk also increases with each subsequent episode (70% with one previous episode, 90% with two previous episodes) and with each first-degree relative (parents, siblings, offspring) who suffers from major depression.⁶¹

The important thing is that major depression is highly treatable. The vast majority of patients respond to antidepressant medications. Most respond to the first agent used, but some require treatment with a second antidepressant. Unfortunately, we cannot "culture the bug" that causes major depression like we can with a sore throat. If we could, we would be able to select precisely the medication that would treat your depressive episode the first time every time. Since we cannot do that yet, we choose the medication that we think is most likely to help you. If you do not respond to it, then we will use a different type of antidepressant. Approximately, 60% of patients will respond to the first medication.¹⁰³ Of the 40% who do not, the majority will respond to the other antidepressants, bringing the overall likelihood of response to approximately 90%.

As you can see, major depression, if treated, has an excellent prognosis and you should be feeling better soon.

• Do I Need to Be on Medications Indefinitely?

For the vast majority of patients, the answer is no. For first-time episodes, we will treat you for 4 to 5 months after you respond (total of 6 months of therapy) and up to 12 months or longer for recurrent episodes. After that period, we will taper and discontinue the medication. (Note: Some researchers advise indefinite therapy if the patient has had three previous episodes.)

We will educate you about the early signs of a recurrent episode when we taper the medication. If you should have a recurrence, this education can help you identify it early and come back for treatment before the episode fully develops.

Some people with recurrent episodes may go years between episodes so that prophylactic therapy with antidepressants does not seem to be reasonable; instead each episode is treated individually, much like recurrent episodes of a sore throat. Although antidepressant medications have been used to prevent recurrent episodes as well as to treat existing episodes, the decision to stay on medication to prevent future episodes is your decision. After all, you are the one who has to put up with the cost of treatment and any adverse effects that the medication may cause. Generally the decision to go on maintenance therapy is made when the episodes become frequent and/or severe. We do not need to make those decisions now and will discuss it more after you have been well for several months.

• Why Did This Happen to Me?

No one completely understands why some people suffer from major depression, although it is clear that patients do not cause or wish themselves to get ill. As we mentioned, the condition runs in families, suggesting an inherited susceptibility. We can think of clinical depression much like any other medical illness such as diabetes or high blood pressure. Medication plays a vital role in restoring normal body function. You play an important role in your recovery by understanding your condition to the best of your ability and by taking an active and committed role in your recovery.