_______________________________________________________________________ Depression and Suicide
Pseudodementia Cognitive impairment often accompanies MDD. Some patients have both MDD and dementia, while others have cognitive impairment that is secondary to MDD, termed pseu- dodementia. Pseudodementia should resolve when MDD is successfully treated. Several clinical features help differentiate pseudodementia from true dementia. When performing cogni- tive tasks, pseudodemented patients generally exert relatively less effort but report more incapacity than demented patients. In the latter group, especially in the advanced stages, patients typically neither recognize nor complain of their cognitive failures, as insight is impaired. In contrast, pseudodemented patients often vehemently complain that they cannot think or remember clearly. Pseudodementia also lacks the signs of cortical dysfunction (e.g., aphasia, apraxia, agnosia) that are seen in degenerative dementia. It is essential that individuals with MDD-related cognitive disturbance not be misdiagnosed and subsequently denied aggressive treatment [22]. INITIAL TREATMENT OF DEPRESSION Although the DSM-5-TR criteria require the presence of five of nine symptoms for MDD diagnosis, significant impairment in functioning can occur with as few as two symptoms [10; 110]. Therefore, the goal of treatment should be to achieve remission, to reduce relapse and recurrence, and to return patients to their previous level of occupational and psychosocial function. Remission is defined as the absence of depressive symptoms, response is defined as a 50% or greater reduction in symptoms, and partial response is defined as a 25% to 50% reduction in symptoms [21; 111]. An estimated 70% to 80% of antidepressants are prescribed in primary care, making it critical that clinicians understand their use and have a system that supports best practices [21]. However, evidence suggests that nonpsychiatric practitioners underdiagnose and undertreat depressive illnesses [43; 112]. Primary care clinicians who diagnose a patient with MDD face several challenges in achieving remission in the patient. These include time constraints on the treatment of a time-intensive disorder; potential comorbidities; lack of training on differen- tial diagnoses; initial patient presentation for a medical and not a psychiatric problem; potential for poor adherence to treatment; unavailability of psychotherapy in many primary care clinics; potential discomfort among primary care provid- ers in providing nonmedical, psychologic care; and patient expectation of a “quick fix” [43]. INITIAL COMMUNICATION WITH THE PATIENT Patient Education An essential aspect of treating major depression is the active engagement of patients and their families during the process. Engagement is the foundation for communication between providers and patients, and at the time of diagnosis, patient
education represents a useful and important topic of commu- nication. Patient education is also important to help counter the negative effects of pessimism, low motivation, low energy, social isolation, and guilt on treatment engagement and adher- ence [21; 22]. Diagnosis, prognosis, and treatment options should be addressed in patient education, which should also include a discussion of the costs, duration, side effects, and expected benefits of treatment. Patients should be reassured that depres- sion is a medical condition, not a character defect, and recovery is the rule, not the exception [21; 22]. Treatment is effective for many patients, and it is important to stress the treatment goal is complete remission—not just getting better but staying well. However, the risk of recurrence is high (50% after one episode, 70% after two episodes, and 90% after three episodes), and patients and family members should be alert to early signs and symptoms of depression recurrence and seek treatment as soon as possible if depression returns [42]. Clinicians should include the following topics related to treatment and follow- up in discussions with the patient before directly addressing specific therapy options [21; 22]: • The causes, symptoms, and natural history of major depression • Treatment options and the process of finding the best fit for each patient • Information on what to expect during the course of treatment • How to monitor symptoms and side effects • The desired follow-up protocol, such as office visits and/or telephone contacts • Early warning signs of relapse or recurrence • The duration of treatment • Communication with the provider • The frequency of visits • Patient expectations and beliefs in the controllability of their depressive symptoms Patient Self-Management Self-management refers to patient ability to manage treatment, lifestyle modifications, and associated physical and psychoso- cial challenges necessary to better ensure recovery from depres- sion. Supported self-management typically includes action planning to change behavior. Techniques include behavioral activation, communication skills, emotion coping skills, patient education, healthy lifestyle, relapse-prevention planning, skill development, and self-monitoring. Effective self-management reduces patient reliance on healthcare providers and increases empowerment and self-efficacy [62; 113]. Behavioral Activation Patients can be instructed to increase their daily involvement in pleasant activities and positive interactions with the envi- ronment as one of the aspects of their overall recovery plan
181
EliteLearning.com/Psychology
Powered by FlippingBook