Psychotherapy: Primary Care Providers =
Partner in Treating Depression

Virginia Montgomery Boney, LMHC, NCC

Introduction

Depressive disorders can affect all aspects of an individual's functioning, and are associated with more than 20,000 suicides and $47 billion in health care costs annually in the United States alone1. Results of the National Co morbidity Survey (NCS)2 provide evidence of a lifetime prevalence for a major depressive disorder to be 17.1%, and women are two to three times more likely to become depressed than men. Additionally, significant co morbidity exists between depressive disorders and other psychiatric disorders (i.e., anxiety, behavioral disorders, and eating disorders)3. Primary care physicians (i.e., family physicians, general internists, and obstetrician-gynecologists) serve as the initial health care provider for between 40% and 60% of individuals with depressive disorders4. Data from the National Ambulatory Medical Care Survey for the 5-year period between 1990 and 1995 reveals that the number of office-based patient visits involving either a (1) new antidepressant prescription, or (2) renewal of an existing prescription, increased 73.4%. Additionally, researchers find that three-fourths of all antidepressant prescriptions are written by primary care providers5. In light of the significant number of individuals being treated for depression by primary care physicians, knowledge of the most efficacious treatment interventions is vital for these practitioners and their patients.

Treatment Practice Patterns

While pharmacological interventions remain the preferred therapy approach among primary care physicians, utilization varies significantly among specialties: family physicians (84.7%), internists (65.2%), and obstetrician-gynecologists (52%). In general, primary care physicians are twice as likely to prescribe antidepressant medication as the sole treatment for depression, as compared to a combined therapeutic intervention consisting of pharmacotherapy and psychotherapy. Among the specialty areas, recommendation of psychotherapy as the sole treatment intervention for depressed patients is most common among obstetrician-gynecologists. Given the prevalence of depression in women in association with specific points in the reproductive cycle6, it is not surprising that referrals for psychotherapy in lieu of pharmacological interventions are more common among obstetrician-gynecologists as compared to other primary care providers.

Benefits of Combined Pharmacotherapy-Psychotherapy Intervention

Increased treatment acceptance, compliance and success

Primary care providers are challenged by patient-related barriers which impose significant limitations upon the treatment of depressive disorders. As many as 40% of patients diagnosed with depression are reluctant to (1) accept the diagnosis, (2) comply with antidepressant intervention, or (3) participate in psychotherapy7. Use of a combined therapeutic intervention (i.e., antidepressants and psychotherapy) to treat patients with depressive disorders can offset these patient-related obstacles to treatment. Empirical evidence demonstrates that ambulatory patients find a combined treatment approach to depression significantly more acceptable, as compared to pharmacotherapy alone8. Another patient-related barrier, noncompliance with medication, is a significant challenge for physicians prescribing antidepressants. The prevalence of partial or total lack of adherence to prescribed dosages is 15-25%9. Ambulatory patients in a 6-month randomized clinical trial receiving only antidepressant medication were twice as likely to be medication noncompliant as compared to participants receiving the combined interven-tion10. In addition, at each 8-week interval in this same study, the difference in success rates between the two groups was statistically significant in support of a combined treatment intervention. The mean success rate in the pharmacotherapy group was 40.7%, as compared to a statistically significant 59.2% in the combined treatment group.

Decreased rate of recurrence

The rate of recurrence of depressive disorders is over 75% (Keller, 1999)11, supporting the need for adequate duration and type of therapeutic intervention. Researchers have found that a combined treatment approach is effective in reducing the rate of recurrence of depressive disorders12. Patients receiving a combined treatment intervention who demonstrated A high adherence to psychotherapy experienced a median rate of depressive recurrence of 102 weeks. In contrast, "low adherence" patients experienced a rate of recurrence that was 5 times greater (18 weeks) than patients demonstrating "high adherence" to psychotherapy. Encouraging patients to continue to participate in psychotherapy as an adjunct to pharmacotherapy not only reduces the likelihood of short-term recurrence, but may also encourage the development of effective coping skills and reduced cognitive vulnerability (i.e., dysfunctional attitudes and negative inferential style).

Patient management

Primary care providers vary widely in their perceived responsibility for treating patient depression and level of confidence in the overall management of depressed patients13. They report concern with organizational barriers to treatment, the most significant of which is limited time to spend with patients. Given the prevalence of co morbidity of depression with other psychiatric disorders and/or substance abuse, increased risk for suicide, and high rate of recurrence, primary care physicians can benefit from partnering with licensed mental health providers (i.e., mental health counselors, marriage and family therapists, social workers, psychologists) to share the burden of managing this higher risk patient. Mental health professionals are trained in assessment of suicidality, and given the prevalence of suicidal ideation among depressed individuals, partnering with these providers enhances the ability of primary care physicians to monitor these higher risk patients. Furthermore, obtaining a patient release of information provides for direct communication between mental health providers and physicians in regard to mutual patients.

Patients participating in psychotherapy generally meet with their mental health provider on a more frequent basis (e.g., weekly, every other week) as compared to their physician visits. Referral of a depressed patient to a licensed mental health professional may (1) reduce physician liability by providing more frequent patient contact with a mental health clinician, and (2) share the burden of patient management with a mental health professional who has received specialized training in the treatment of depression and other psychiatric disorders. Many licensed mental health providers are knowledgeable of psychotropic medications, and as a result, encourage patients to contact their primary care physician in cases requiring (1) a change in dosage, (2) a change in medication, (3) obtaining a new psychotropic prescription, or (4) obtaining a referral to a psychiatrist.

Finally, depression often impairs an individual's psychosocial functioning, and studies provide strong support for the efficacy of psychotherapy in treating the psychological and social manifestations of depressive disorders14. Psychological manifestations of depression include an individual's attributions, attitudes, personality, and ability to cope. Interpersonal complications of depression include impaired relationships with family, friends, children, co-workers, and employers. Researchers have found evidence a positive association between vulnerability for clinical depression and/or suicidality and lack of social support15. Primary care physicians who encourage their depressed patients to participate in psychotherapy (1) increase the efficacy of treatment by providing the opportunity to reduce the psychosocial complications and impairment that depressed patients often experience, and (2) increase the social support available to patients through the therapeutic relationship which may reduce the likelihood of suicide.

Psychotherapy: A nonpharmacological intervention

Knowledge of the efficacy of psychotherapy in treating depressive disorders is essential in offering patients a nonpharmacological intervention in those circumstances where (1) other prescribed medications may interact with psychotropics, (2) lack of tolerance for side effects exists, or (3) there is a high risk of deliberate self-harm (i.e., potential to overdose on medication). Since the prevalence of depression is significantly greater among women, and about a third of young adult women identify an obstetrician-gynecologist as their primary care physician16, obstetrician-gynecologists generate more referrals for psychotherapy as the sole treatment intervention for depression than other specialists.

Female reproductive issues may increase the need for nonpharmacological treatment approaches as an alternative to pharmacological interventions for depressive disorders. For example, depressed female patients who are trying to become pregnant or are already pregnant, or are nursing an infant, may not be suitable patients for antidepressant medication. If a female patient being treated for depression with pharmacotherapy discontinues her medication because of pregnancy, she increases her risk of relapse by 50% during the course of her pregnancy17. Treatment of depression during pregnancy, regardless of the therapeutic intervention, is a significant clinical issue for physicians because of the increased risk of poor prenatal care, substance abuse, suicide, and obstetric complications18 . Psychotherapy alone can be an effective alternative treatment intervention to assist a pregnant patient in managing her depression and maintaining an adequate level of functioning until she is able to resume pharmacological treatment. Researchers have found that less severely depressed patients participating in psychotherapy alone can achieve outcomes similar to those of combined interventions19.

Several short-term psychotherapy models have demonstrated efficacy in reducing depressive symptoms and increasing an individual's level of functioning. Short psychodynamic supportive psychotherapy (SPSP) is a supportive therapeutic approach that utilizes systematically supportive interventions (e.g., reducing anxiety, reassuring, enhancing self-esteem, reframing symptoms as problem-solving attempts, encouraging, and encouraging limited ventilation20). Cognitive-behavioral therapy (CBT) focuses on identifying and modifying an individual's dysfunctional attitudes and negative attributional style. Empirical studies support a significant positive association between these cognitive factors and clinical depression21. The efficacy of CBT alone in treating depressed individuals has been found to be about 15% higher than pharmacotherapy 22. In contrast, depressed individuals being treated with pharmacotherapy alone are twice as likely to be noncompliant with treatment, as compared to a combined intervention of CBT and antidepressant medication23.

Summary

Primary care providers are the initial health care provider for a significant number of depressed individuals. Incorporating a combined treatment intervention of pharmacotherapy and psychotherapy is often a more efficacious treatment approach than either intervention alone. Additionally, referring depressed patients for psychotherapy may (1) increase treatment acceptance and compliance, (2) increase treatment success rate, (3) decrease the risk of depressive relapse or suicide, and (4) share responsibility for patient management with licensed mental health professionals.

References

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  18. Kornstein SG. The evaluation and management of depression in women across the life span. J Clin Psych 2001;62(suppl 24):11-17.
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  22. US Department of Health and Human Sciences (1993) Depression in Primary Care: Treatment of Major Depression. AHCPR Publications, Rockville, USA.
  23. US Department of Health and Human Sciences (1993) Depression in Primary Care: Treatment of Major Depression. AHCPR Publications, Rockville, USA.
March/April, 2002/ Jacksonville Medicine

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