Common Mental Disorders Depression - New Zealand Doctor

should continue in this group for the first few weeks, until they are considered to be
no longer at significant risk, then at least 2 weekly until there is clear improvement. 65
Face-to-face assessment is preferable.
In the initial stages of treatment the practitioner should continue to enquire about
suicidal ideation and about any increase in symptoms. In the first few weeks of
treatment with an SSRI, an increase in anxiety, restlessness or agitation may occur.
This can be very distressing and may be associated with increased suicidality.
Patients should be advised to contact the practitioner if this happens. A change
of medication could be discussed in these circumstances if the cause appears
to be related to medication rather than other stressors. 65
Treatment resistance
Treatment resistance is defined as lack of a satisfactory response after trial of two
antidepressants given sequentially at an adequate dose for an adequate time (with
or without psychological therapy). Patients who respond to treatment but do not
subsequently continue improving to the point of remission could be considered in this
category. If a patient is treatment resistant, the practitioner should refer urgently to
secondary care mental health services while continuing to treat the patient. 9 The GDT
advises that augmention with lithium may be considered. Other strategies include
changing to a TCA (eg, nortriptiline) or venlafaxine. 9
If a patient is transferred into the care of secondary care mental health services,
primary care monitoring should continue in order to support treatment and aid the
eventual transition back to primary care for longer-term management. 346
Subtypes of depression
Melancholic depression
A person with melancholic depression typically presents with marked physical slowness
or marked agitation, a range of somatic symptoms and a loss of pleasure in almost
all activities. 243 The practitioner should assess the patient to exclude bipolar disorder.
In the opinion of the GDT, a TCA (eg, nortriptyline) is appropriate as a first-line
antidepressant for melancholic depression. Secondary care consultation or referral
could also be considered. 9
The GDT notes that a positive attempt to discriminate between melancholic and
non-melancholic forms of depression is at least as important as distinguishing
between moderate and severe depression, as treatment decisions and the need
for referral can be highly influenced by this distinction.
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Identification of Common Mental Disorders and Management of Depression in Primary Care