Common Mental Disorders Depression - New Zealand Doctor

Overall, the evidence suggests that psychological therapies and antidepressants are of
comparable efficacy. 65,331-333 Psychological therapies are better tolerated, 65 and may
have a more sustained effect, 334,335 though the GDT notes that access to these therapies
can be difficult due to barriers of cost and accessibility. Secondary care evidence
suggests that combined therapy appears to enhance the effectiveness and tolerability of
treatment for people with more severe depression, 65 or with residual symptoms, 65 though
it is not indicated in the initial stages of mild or moderate depression. 9,65
Studies favouring exercise and guided self-help strategies have been conducted almost
exclusively in volunteer populations but their findings may reasonably be applied to
adults in primary care, particularly those with milder forms of depression. 65 Similarly,
a number of self-management interventions, such as sleep hygiene and activity
scheduling, have not been the subject of controlled research trials, but are supported
by international expert opinion and appear to be reasonable strategies for adults with
depression 65 (see Appendix F: Self-management Resources).
Some patients, particularly Mäori and Pacific peoples, may choose other approaches
including prayer (karakia) or traditional healing practices (eg, rongoä) and other
providers, such as tohunga or spiritual leaders. 22,151 The role of the primary care
practitioner is to be aware of any alternative therapies the patient is using, work
with their beliefs and seek a compromise if necessary. Both traditional and Western
medicine can be usefully employed in patient treatment. 151
There is emerging evidence that depression is biologically heterogeneous and that
different treatments differ in the likelihood of achieving remission in different patients. 336
When planning the management of an adult with depression, the practitioner
should consider: symptom severity and symptom persistence, functional impairment;
response to any previous intervention, and the individual’s wider psychosocial context,
identifying factors that may impact positively or negatively on outcomes.
Providing active support
Successful management of depression depends largely on enabling the patient
to be an active participant in the care process. 143 A collaborative partnership
between the practitioner and patient is a consistent predictor of therapy outcome
for both psychological 144,145 and pharmacological treatments. 146,147 Integral to this
partnership is agreement between practitioner and patient on the tasks and goals of
treatment. 136,145,148,149 The practitioner should endeavour to build a supportive and
collaborative relationship with an adult with depression and their family/whänau.
The needs and resources of family and whänau should also be integrated into the
care plan, as they can provide the intimate support networks that help facilitate
patient self-management changes and meet treatment goals. 150
The practitioner should signal clearly to the patient and supporting family/whänau
that the disorder is a significant issue that requires follow-up. Provision of accurate
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Identification of Common Mental Disorders and Management of Depression in Primary Care