_______________________________________________________________________ Depression and Suicide
Eating disorders can co-occur with depression. CBT is suggested in patients with bulimia nervosa; other effective therapies include interpersonal therapy, group therapies, family therapy, and SSRIs. Bupropion should be avoided due to lowered seizure threshold, and ECT has not been shown effective [22]. If depression is identified as seasonal affective disorder, bright- light therapy is recommended as first-line therapy and can be used adjunctively with antidepressants in more severe cases. The entire range of MDD treatments may also be used for seasonal affective disorder, either combined with, or in place of, bright-light therapy [22]. Persistent Depressive Disorder and Pseudodementia Antidepressants appear to benefit some patients with persis- tent subthreshold depressive symptoms (dysthymia) but lack benefit in patients with recent-onset subthreshold depressive symptoms. No clear advantage has been shown among specific antidepressants, and psychotherapy should be considered [122; 68]. For patients with persistent subthreshold depressive symp- toms or depression with mild-to-moderate severity, consider an antidepressant or CBT, interpersonal therapy, or behavioral activation [68]. Unlike true dementia, cognitive impairment in pseudodementia is secondary to MDD, and should resolve with adequate antidepressant or ECT response [22]. Demographic and Psychosocial Factors Influencing the Treatment Plan Female Sex Some women experience mood fluctuation with gonadal hormone levels, and assessment should include a detailed assessment of mood changes across the reproductive life his- tory. Potential drug-drug interaction should also be consid- ered when selecting an antidepressant in women taking oral contraceptives. In perimenopausal women, SSRI and SNRI antidepressants are useful in ameliorating depression as well as in reducing somatic symptoms such as hot flashes [22]. Major Psychosocial Stressors An MDE may follow an adverse life event, often surrounding the loss of an important relationship or life role. Antidepres- sant treatment decisions for MDE following such events do not differ from other contexts, but the influence of past and current psychosocial stressors on MDE severity should be considered. Adding a psychologic treatment to medication may be particularly useful [22]. Antidepressant medications and/or psychotherapy should be used in prolonged reaction to relationship loss with significant functional impairment, and some patients may benefit from bereavement support groups [22].
A history of early-life trauma, such as physical/sexual abuse or parental loss or abandonment, should be considered in treat- ment selection. A study of 681 patients with chronic MDD found that among patients with childhood trauma, CBT was consistently more effective than antidepressant monotherapy, and that combining both therapies had no significant advan- tage over CBT monotherapy [123]. Remission was estimated to be twice as likely with psychotherapy than antidepressants, with special benefit noted in patients with early parental loss. These results suggest a preferential response to psychotherapy in patients with chronic MDD and a history of childhood trauma [123]. An ongoing family stressor can interfere with treatment response. Ambivalent, abusive, rejecting, or highly dependent family relationships can influence development or persistence of MDD. Such families should be evaluated for family therapy, which may be used in conjunction with individual and phar- macologic therapies [22]. Other Psychosocial Factors Psychosocial stressors such as housing, food, childcare, trans- portation, employment, immigration status, and financial stability may be more prevalent in certain populations and should be considered during treatment planning [124]. Also, financial factors such as insurance coverage or generic versus brand name medications can affect treatment adherence. Among low-income minority women in the United States, availability of childcare and transportation are associated with significant improvement regardless of treatment modality. Medication noncompliance rates are higher in intercultural settings due to cultural expectations and communication problems [21; 125]. Cultural Factors Essential to effective diagnostic assessment and clinical man- agement of depression is an understanding of the cultural context of a patient’s illness experience. Culture is the systems of knowledge, concepts, rules, and practices that the patient has learned over time and includes language, religion and spirituality, family structures, life-cycle stages, ceremonial ritu- als, customs, and moral and legal systems [10]. Ethnic minority and immigrant patients can experience many barriers to accessing mental health services, including stigma, deficits in knowledge/understanding, economic hardship, and language barriers [126]. Clinicians should take steps to address their own cultural competency when working with minority patients and ensure that all communications are clear and thorough, utilizing an interpreter when necessary. Different beliefs, values, and terms for depression will impact the perceived effectiveness of treatments. In addition, some cultures may be more likely to utilize alternative treatments (e.g., saffron) [126].
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