MOOD disorders such as major depression can be complex and time-consuming to treat. The burden of diagnosing them, and much of their management, falls squarely on the shoulders of GPs. Two new guideline summaries from the Royal Australian and New Zealand College of Psychiatrists (RANZCP) – one for major depression and the other for bipolar disorder  – give GPs evidence-based recommendations and new treatment algorithms to help them in this challenging area.

The depression guideline emphasises a biopsychosocial approach to management, and suggests that for less severe presentations, lifestyle and psychological therapies should be favoured. Antidepressants should be added for more severe and difficult-to-treat cases.

Dr Mukesh Haikerwal, AC, a Melbourne-based GP and beyondblue board director, says that the way depression is managed has changed massively over the period he has been practising.

“I think we have a much greater understanding of depression and the importance of diagnosing it early. That’s coupled with much better treatment options than we had before. The tricyclic antidepressants that we used to prescribe had terrible side effects and were imperfect in their treatment successes. The new medications that came through, the SSRIs [selective serotonin reuptake inhibitors] and SNRIs [serotonin–norepinephrine reuptake inhibitors], meant there were many more useful and good treatments in our armamentarium. So not only did we know how important depression was in our community, we actually had the tools to start treating it.”

Dr Haikerwal, a former president of the Australian Medical Association who was made Companion of the Order of Australia in this year’s Australia Day honours, says another major impact on treating depression was the introduction of mental health plans, which made it easier for GPs to work with psychologists.

“It’s completely transformed our ability to look after people. It’s very important. And there’s a third significant way in which things have changed, which is that there’s a much greater awareness of depression in the community. People like Jeff Kennett at beyondblue helped normalise depression and anxiety, to the level where people will talk about it and seek help. There was a time when it was very hard to get people to admit they had a problem and needed treatment. But increasingly they’ll come in and say ‘I’ve got depression’, and they’re probably right.”

But Dr Haikerwal cautions that there remain significant barriers to treating depression in primary care, particularly economic ones.

“It’s time-consuming to manage and you have to have a certain sort of practice that allows you to do that, ideally one with support psychology services. And because you need more time with these patients, you have to be prepared to charge them for it, or take a financial hit yourself. The Medicare system tends to penalise doctors with an interest in mental health, which is absolutely ludicrous and an ongoing challenge. In my practice we have 15 or 16 GPs and 10 psychologists on site, which is wonderful. We took a decision to look after these people better, even if it’s not necessarily the best thing to do financially.”

Managing bipolar disorder in primary care is also a challenge, even if the difficulties are quite different.

Professor Malcolm Hopwood, a co-author of the RANZCP guidelines for bipolar disorder and a former RANZCP president, told MJA InSight that the condition typically presents in primary care as depression.

“It’s a challenging diagnosis, and it relies particularly on picking up on the presence of mania. One key point is that we want all physicians to have a high level of suspicion for detecting early signs of mania and initiating prompt treatment. It’s very important that people with difficult-to-treat depression should be asked about past symptoms of hypomania.”

Professor Hopwood says that pharmacological treatment can be complex and the drug regimen is quite different from that of a person with a unipolar disorder such as major depression.

“Combination treatment – the use of mood stabilising agents and second-generation antipsychotics – is often central. These are agents that need careful prescription, with risks such as metabolic side effects, so involving specialist care may be appropriate.”

He says that lithium remains the first-line treatment for bipolar disorder, although it needs careful monitoring as it doesn’t suit every patient.

“But finding one treatment that meets all management needs may be difficult, so we acknowledge in the guidelines that combinations are often required,” he adds.

Early diagnosis and intervention is critical and an area that needs improvement, Professor Hopwood says, adding that the gap between first symptoms and diagnosis is typically around 8 years.

He says that one big shift in the management of bipolar disorder has been an increasing focus on poor general health in this population.

“Like people with schizophrenia, these people have a much lower life expectancy than the general population, and that’s not really acceptable. Most of this is due to poor health rather than higher rates of suicide. It’s a combination of diet and lifestyle issues, and poor attendance to medical care. It’s something we really have to focus on.”

 

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6 thoughts on “New guidelines for mood disorders in primary care

  1. Dr Margaret Taylor MB.BS,BSc,FACNEM says:

    As well as referral to psychologists we GPs need to look for the basic causes of depression – iron deficiency, marginal thyroid deficiency – with TSH in the upper normal range and some of the symptoms of low thyroid eg feeling the cold, cold hands and feet, loss of lateral eyebrows, not sweating, weight increasing, high cholesterol, fatigue and foggy brain. Also coeliac antibodies and B12. Then Felice Jacka’s research showing that depression is preceded by poor diet (especially in teenagers) and that the Mediterranean diet is as effective as SSRIs. So maybe a referral to a dietician first, before the psychologist.

  2. Anonymous says:

    I think there is so much propaganda for psychology and care plans, and people just want these when we try to talk to them due to unnecessary repetative visits and loss of self confidence in being able to deal with it them selves, GP, or close friends or parents. usually social loss of contact is important factor

  3. Anonymous says:

    It is interesting that no-one has mentioned that therapy of a supportive or more insight based kind is vital in treating depression and anxiety disorders. Simply prescribing SSRIs will be unlikely to lead to a long lasting improvement. Longterm studies conducted by drug companies and by psychiatrists have shown that some kind of talking cure is essential with these conditions. Supportive or more insight oriented therapies have a significant evidence base for improvement.
    I also note that psychiatrists are not mentioned at all in the pathway for diagnosis or treatment and wonder why this is the case? It seems that General Practice has been identified as being solely responsible for diagnosis and treatment of mental health disorders, when GPs may not have the training to either diagnose or manage these conditions. Furthermore GPs may not wish to take full responsibility for mental health disorders of all kinds, as they may not with to invest the significant amounts of time required for such treatments.
    Beyond Blue has perhaps lead the way here as they rarely refer to psychiatrists, as if GPs suddenly know how to treat anxiety and depression successfully.

  4. Anonymous says:

    As far as I can recall, one has to address the issue /s causing the patient to have mental health problem. There are times that problem are short lived because the issue/ s have been resolved.
    I think , yes they need to be seen by psychologist even medications & psychiatrist if needed, however, the root cause should be looked into and dealt with accordingly.
    Also, checking for medical problem/s that may relate to this should be done as commented earlier.

  5. Gina says:

    I wonder how often these mental health experts screen people for ME/CFS before prescribing their psychosical approach?? Causing great harm to the patients that have a physical and not a mental health issue.

    http://www.virology.ws/2018/02/05/trial-by-error-letter-to-british-journal-of-sports-medicine-from-cpet-experts/

  6. Paul B. says:

    “That psychiatrists are not mentioned at all in the pathway”.

    Well, that depends on whether there is actually a psychiatrist *available* – within a plausible timeframe.

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