Common Mental Disorders Depression - New Zealand Doctor

When patients are awaiting consultation with secondary care services, the GDT
advises that antidepressant therapy should normally be initiated by the primary care
practitioner. The patient needs active support and regular reassessment during the
waiting phase for secondary treatment, and the patient and family need to know how
to access help at all times of day. If the patient is at risk of suicide, family/whänau
and others should be advised of the need for close observation and to remove
potential suicide means, such as obvious ligature points, firearms and toxic substances
(including unnecessary medications) from the household. 127
All patients with moderate to severe depression should be offered active support and
advice on self-management as appropriate, and the choice of an antidepressant
or a psychological intervention. 9,65,255 Their choice of treatment will depend on
personal preference, past experience and the availability and cost of psychological
therapies. 347 The practitioner should also offer the patient the option of referral to
other psychosocial support agencies and action the appropriate referrals (eg, social
workers, Community Alcohol and Drug Services).
For patients who choose it, a brief psychological intervention is suitable as a first-line
treatment for moderate depression (eg, CBT or structured problem-solving therapy
[PST], 6–8 sessions over 10–12 weeks). 65 Structured PST is likely to be the most
accessible form of psychotherapy for primary care practitioners. PST aims to teach the
person to re-engage with practical approaches to perceived problems and to generate
preferred solutions. 277 It can be a useful means of securing the involvement of other
key people in the family/whänau, who should be encouraged to suggest additional
options or assist with implementation. Practitioners must not simply offer their own
advice or solutions. PST can be readily learnt by a member of the primary care team
and can be delivered in short sessions within a manageable time frame. 277 The
National Institute for Health and Clinical Excellence (NICE) guideline suggests 6 to
8 sessions over 10–12 weeks. 65 This should be followed by a review in primary care:
some patients will need further sessions or more intensive treatment. Improvement
with psychotherapy may be slower than with antidepressant medication. If there is no
marked clinical improvement after 6 sessions of treatment it is reasonable to consider
changing or augmenting treatment (eg, by adding an antidepressant). 9,255,347
For a patient with more severe depression, a longer structured psychological intervention
is an appropriate first-line treatment (eg, 16–20 sessions CBT or IPT), 65 if this is
available. The GDT notes the need for more widespread access to these treatments
in primary care. Psychological therapies offered should use a recognised therapeutic
approach that targets depression and related problems, and that focuses on behavioural
support. Fully trained and accredited therapists should be used. 9,65
For a patient presenting initially with severe depression, a combination of antidepressants
and a structured psychological intervention (eg, 16–20 sessions CBT or IPT) should be
considered, as the combination is more effective than either treatment on its own. 65
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Identification of Common Mental Disorders and Management of Depression in Primary Care