Treatment Of Major Depression

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Treatment interventions are divided into two sublev-els: (1) case identification, to provide early treatment for cases of major depression that have not been identified previously; and (2) standard treatment, which accounts for the bulk of mental health intervention efforts.

The need for case identification efforts arises from the underdiagnosis of major depression and other depressive disorders in primary care clinics. Only 20% of individuals who meet criteria for major depression seek mental health services. However, more than 70% of those who meet criteria for major depression do seek health care, generally from a primary care physician. Yet, only about a third of individuals with major depression are so identified by their primary care providers. It is imperative, therefore, that primary care physicians and other health care providers learn to identify cases of depression so that individuals suffering from them may receive appropriate interventions.

Major depression is eminently treatable. Between 60% and 80% of individuals with major depression respond to either psychological or pharmacological treatments. Other less common types of treatment, such as light therapy and electroconvulsive therapy, have also been found effective for certain cases of major depression.

Treatments for depression vary in their theoretical assumptions and in the specific interventions used with patients. Certain common elements include an explicit helping relationship between the therapist and the patient, the identification of depression as a clinical disorder that requires treatment (as opposed to some type of "personal weakness''), an explanatory framework for the mechanisms that trigger and maintain the depression, and implicit or explicit recom

Depression — Applied Aspects mendations for patient behaviors that are expected to bring about improvement.

Many types of psychological approaches are currently used in the treatment of depression. Those that have been most often subjected to randomized controlled outcome trials are the cognitive - behavioral therapies. Cognitive - behavioral therapies for depression are based on the hypothesis that mood is influenced by a person's cognitive and behavioral patterns. These patterns have been learned, usually in a social context, and can be modified. The purpose of therapy is to work with the patient to identify the cognitions (thoughts, assumptions, other mental processes) and behaviors (activity levels, interpersonal skills, and other physical or observable actions) that are most related to specific mood states. The goal of therapy is to reduce cognitions and behaviors that increase the probability of depressed states and augment those that decrease the probability of depression. [See Behavior Therapy; Cognitive Therapy.]

Another psychological approach to depression that has been repeatedly evaluated in randomized trials is interpersonal psychotherapy. This approach focuses on the influence that the interpersonal context has on triggering and maintaining depressive mood. The therapist reviews with the patient current and past interpersonal relationships as they relate to depressive symptoms. The focus of therapy usually centers on one or more of four major areas: grief, interpersonal disputes, role transitions, and interpersonal deficits.

Other psychological treatments have not been studied as extensively. However, brief approaches to therapy that specifically target depression have generally shown encouraging results.

Pharmacotherapy for depression has also been subjected to many randomized controlled trials. There are several types of antidepressants, all of which have approximately the same efficacy. Those developed most recently tend to have fewer side effects and lower lethality if used to attempt suicide. Pharmacotherapy is probably the most commonly used form of evidence-based treatment for depression in the United States, in part, because it is much more available than the psy-chotherapies. Antidepressants are prescribed at least as often by nonpsychiatric physicians as by psychiatrists. This has led to a strong (and controversial) emphasis on educating primary care providers to detect and treat depression in their setting before re ferring to mental health care providers. [See Psycho-pharmacology.]

Results of randomized trials do not always agree. Nevertheless, the preponderance of the evidence indicates that pharmacotherapy, cognitive - behavioral therapy, and interpersonal psychotherapy are all significantly effective in the treatment of major depression. The rate of improvement is generally faster for pharmacotherapy, but total improvement over a 20-week treatment is generally comparable across treatments, especially for mild and moderate cases of major depression. There appears to be some advantage to pharmacotherapy for more severe cases of depression, and clearly so for cases of depression with psychotic features in which antidepressants and antipsychotics may be prescribed simultaneously. A combination of psychotherapy and pharmacotherapy is often used in the treatment of depression. Most controlled studies have shown either additional improvement or no detectable difference in efficacy when both treatments are used. There appears to be no general disadvantage to the use of combined treatment. A major problem with treatment for depression is the high rate of relapse. This leads to a focus on maintenance strategies.

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