Depressive Disorder-Related Practice Change

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Table of Contents

Practice Problem
Practice Change
Population
Intervention
Comparison
Outcome
Timing
Feasibility
References

Practice Problem

Depressive disorders are quite common diseases, affecting 10-15% of the world’s population each year (Park & Zarate, 2019). Despite advances in the development of psychopharmacology and the identification of individual biomarkers of depression, only 60-70% of patients with depression who respond to treatment respond positively to antidepressant therapy (Park & Zarate, 2019). A number of studies on the satisfaction of life of patients with depression show that in addition to receiving antidepressant therapy, they also need additional psychosocial measures to achieve complete remission.

The reason for the increased difficulties in early diagnosis of depression among young adults between 18-40 y/o in primary care practice in recent decades can rightfully be called the replacement of a consistent, strictly structured analysis of the state on the basis of a medical conversation. It was replaced by a simplified procedure for operational diagnostics based on a particular set of criteria.

In itself, the principle of diagnostics based on certain criteria is an undeniable achievement. It is assumed that it should prevent unreasonable “freedom” in the formulation and justification of the diagnosis and ensure its reproducibility (Park & Zarate, 2019). However, this principle does not take into account the patterns of the formation of the syndrome and the general clinical, biological and compensatory psychological elements of the state.

In addition, it should be considered that the authors of the relevant criteria themselves did not always follow the rules of evidence when forming one or another of their compositions, which is formally sufficient to establish a definite diagnosis. So, in modern DSM-V classifications, the operational diagnosis of depression uses the following as equivalent alternative signs (Park & Zarate, 2019). This is a decrease or increase in appetite, a decrease or increase in body weight, insomnia, or hypersomnia. If each of the first signs of these binary combinations is typical for a depressive syndrome, then the second indicates an atypical structure of depression. Such a broad interpretation is suitable for a population study but not for a differentiated, individualized diagnosis of an affective disorder.

Practice Change

Early diagnosis of depression is a complex process that requires increased effort on the part of both the physician and the patient. It is important to maintain a therapeutic alliance with the patient and almost permanent psycho-educational activities (Davey & McGorry, 2019). Patients with the suspected depressive disorder should share their inner experiences with the doctor and be able to freely ask any questions related to risk factors for depression, lifestyle changes, more effective treatment options for depression, duration of treatment, the severity of side effects, as well as suicidal thoughts and aggressive behavior.

The doctor, in turn, should discuss with the patient the issue of adherence to treatment and the impact of comorbidities (such as cardiovascular disease, cancer, thyroid disease, and eating disorders). Moreover, the interaction between antidepressants and other drugs, possible manifestations of future relapses of depression, and factors of increased vulnerability to it should be discussed (Park & Zarate, 2019). It is important to inform the patient that ignoring the symptoms of depression predicts a worse long-term outcome while achieving a state of certainty is associated with a more favorable course of the disease.

Moreover, there is a necessity to develop an appropriate treatment strategy for young adults who might have resistant depression at the early stages of diagnosis. There is no single standard approach to treating depression-resistant depression, so a patient with this condition needs an individualized treatment plan that may take time and effort. Therefore, the following principles should be followed when treating patients with therapy-resistant depression. It is necessary to determine the exact diagnosis, including the subtype of depression, and assess concomitant mental and physical illnesses. It is recommended to determine the applicability of the strategy of prescribing Aripiprazole, a dopamine system stabilizer that is pharmacologically different from other antipsychotics, acting as a partial agonist of dopamine D2 and D3 receptors, serotonin 5-HT1A receptors, and serotonin 5 antagonists (Taylor et al., 2019).

Population

Population for the practice change involves patients of age 18–40 years who are classified as young adults. Inclusion criteria are compliance with the clinical picture of non-psychotic depressive disorder with one of the following diagnostic headings. Among them are depressive episodes of mild, moderate degree; dysthymia; mixed anxiety and depressive disorder; adjustment disorder. Exclusion criteria are organic mental disorders, schizophrenia and schizophrenia spectrum disorders, psychopathy, and mental retardation.

Intervention

The primary aspect of intervention will be the shift towards the approach to early diagnosing of depression among young adults in primary care practice. As mentioned above, there is the issue of over-reliance on specified criteria during this process. The section on practice change suggests appealing to individualized and even “improvised” diagnosing of depression within the scope of the theme. It will be crucial to develop as the open and complex conversation with the patients as possible. Then, at the initial stages, the necessary analyses in the framework of defining the appropriacy of prescription of Aripiprazole in case of resistant depression should be made.

Comparison

The main difference between the suggested practice change to the prevalent practices in this vein will be the adherence to the approach of individualized and “improvised” discussion with the patient on his or her state and risk factors related to the presence of depression. However, here, it can be noted that the application of DSM-V may be used as well – if the physician considers such an option relevant at the early diagnosing stages. Then, the significance of Aripiprazole should be explored and shown too. The study showed the effectiveness of Aripiprazole in the treatment of resistant depression (McDermott & Dozois, 2019). The authors showed that patients who received this drug as adjunctive therapy showed a better therapeutic response compared to placebo and achieved remission.

Outcome

It is expected that the described approach will benefit the related practices to a great extent. In particular, there may be an increased number of timely diagnoses of depression among young adults in primary care practice. The individualized strategy will take into account vital aspects that specified diagnostic criteria can miss at times. Moreover, the activities in the framework of Aripiprazole prescription can significantly reduce the cases of severe resistant depression.

Timing

It might be assumed that the practice of non-adherence to the established and generally accepted diagnosing criteria cannot be implemented promptly and without preparations. In particular, the development of the related recommendations on how to conduct the individualized conversation with the patients will take from one to two months. Then, in order to create significant practical experience and knowledge, such a strategy should be realized among the reputable and recognized facilities and professionals, which will take at least six months. After the scientific approbation of the results – from one to two months – the practice change may become a generally accepted approach.

Feasibility

Despite the fact that the practice change is likely to bring many benefits, its implementation involves many resources – starting from primary care facilities and ending with healthcare professionals. Prior to the practice’s realization, a considerable degree of work should be done. Particularly, patterns for individualized conversations with the patients are to be developed by respected mental specialists and agreed with the facilities that will potentially use them. Then, the efficiency of this shift

References

Davey, C. G., & McGorry, P. D. (2019). Early intervention for depression in young people: A blind spot in mental health care. The Lancet: Psychiatry, 6(3), 267–272.

McDermott, R., & Dozois, D. J. A. (2019). A randomized controlled trial of Internet-delivered CBT and attention bias modification for early intervention of depression.Journal of Experimental Psychopathology. Web.

Park, L. T., & Zarate, C. A. (2019). Depression in the primary care setting. The New England Journal of Medicine, 380(1), 559–568.

Taylor, R. W., Marwood, L., Greer, B., Strawbridge, R., & Cleare, A. J. (2019). Predictors of response to augmentation treatment in patients with treatment-resistant depression: A systematic review. Journal of Psychopharmacology, 33(11), 1323–1339.

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