CHAPTER 4: General Considerations in Treatment

INTRODUCTION

Once a patient with potential depression is identified, comprehensively assessed, and the subtype of his/her depression defined (Chapter 3), the next task is to engage the patient in developing a treatment plan composed of evidence-based interventions to be implemented at the appropriate stage of their depression. Providing a choice of interventions and their respective benefits versus side effects is one way to engage the patient in planning treatment and improves adherence and outcomes.¹ The timing of the intervention is also important; for example, patients with severe depression are often unable to fully engage in cognitive behavioral therapy (CBT) and profit more from CBT if it is introduced during milder stages of illness or once recovery has begun.

Aiming for complete remission and optimal functioning improves outcomes. Patients who experience residual subthreshold symptoms demonstrate a more severe course of illness and experience a relapse or recurrence three times faster than patients who achieve a full remission.²

Achieving full remission and optimal functioning improves the mental health prognosis, and may also improve the course of the comorbid medical disorders. Some examples are as follows:

• Patients with depression following stroke are more likely to die from complications of their stroke.³

• Patients with diabetes and depression have worse glycemic control and higher rates of diabetic complications.⁴

• Patients with untreated depression are at greater risk of arrhythmia following myocardial infarction and other cardiac diseases than are those without depression (Chapter 7).

The care of patients with medical disorders and comorbid depression costs up to twice that of patients with chronic diseases who are not depressed.⁵ It is important to note that only a fraction of these increased costs (about 1%) are attributable to mental health care. Indirect costs are substantial and include lost income and employer costs due to missed work. Costs go well beyond the monetary and also include poorer quality-of-life and increased suicide rates.^6,7 Effective treatment of the depression is likely to lower overall healthcare costs. For example, older adults with major depression or dysthymic disorder who are managed using an integrated depression care model (Chapter 23) are twice as likely as those with nonintegrated care to have at least a 50% reduction in depression symptoms,⁸ and reduced total healthcare costs.⁸

In summary, treating depression to remission and minimizing risks for recurrence not only benefits patients and their families; it also has the potential to lower the costs of care and limit the other wider societal burdens of depression. In this chapter, we address methods for approaching and engaging the patient with medical illness and depression, the nuances of treating depression in the context of medical comorbidities, and the measurement of the patient's progress during treatment.

APPROACH TO THE PATIENT

The first step to successful ...