Anita H. Clayton, M.D.
Chair, Department of Psychiatry & Neurobehavioral Sciences
University of Virginia School of Medicine
The mental health care system is overburdened, so it’s a comfort to know that primary care providers are generally capable of starting a person’s depression treatment. In fact, about two-thirds of antidepressant prescriptions are written by primary care providers. If you’ve read the past several posts here on Care for Your Mind (see the list in resources below), you’ll know to communicate with your health care provider to decide on the treatment that is the best fit for you. In this post, Dr. Anita Clayton provides you with strategies and helps you set reasonable expectations for treatment.
If you can’t see a psychiatrist
If you can’t see – or don’t want to see – a psychiatrist or other mental health prescriber, don’t worry. Every primary care provider – your regular doctor, nurse practitioner, or other health professional with prescribing authority – can find out about side effects for the different medications in order to tailor your treatment. However, if you’ve gone through one or two medications at an appropriate dosing level and for an appropriate amount of time and still not seeing results, it may be time for a referral to a psychiatrist or psychiatric nurse practitioner. If there is not one available locally, using a tele-mental health service may be a good option. Psychiatrists are able to provide consultations for people throughout the U.S. Additionally, specialists, especially psychiatrists, can help your primary care provider to develop the best treatment algorithm for you.
Ways to get to the issues that matter
For more than twenty years, we’ve had screening tools that can be used routinely to determine a baseline and changes in a variety of health areas. I think everyone can use a questionnaire with their patients and create the framework to discuss all of the aspects of a person’s health and wellness, whether it’s weight, sexual function, concentration, depression, anxiety, or something else. These questionnaires are useful for initiating the conversations that patients, providers, and families need to have to find that path toward wellness.
In my experience, patients come to the appointment with their own agenda about what’s bothering them and what’s important, but often do not share their concern(s) with the provider. Here’s a way for the provider to take the lead in getting to the issues that matter. It will save everyone’s time. I encourage primary care providers to give patients the opportunity to discuss concerns that make them feel uncomfortable early in the appointment. It saves time and patients appreciate the better care. On the flip side, patients can utilize online or other screening tools and bring those results to their treatment team.
What you can do when there’s no progress with treatment
If you are (or your loved one is) not getting better and your primary care provider is not addressing your depression, or not addressing your depression in a way that reflects your preferences and priorities, ask to see a specialist, or a colleague of theirs, or just change your doctor. I recognize this is not an easy task, especially if there aren’t many convenient or covered options, but you deserve depression treatment that works for you. Health care providers want you to be successful.
Medical leave is to get well, not sit around
I have concerns about people taking medical leave and how they spend their time. Just taking leave is not enough. For a primary care provider to help someone get medical leave (paid or unpaid) from work so they can get well makes sense in many cases, but that needs to be paired with actively pursuing treatment so the person gets well. Providers should help their patients prepare to return to work with aggressive depression treatment. Without treatment, we’re creating potentially avoidable disabilities and not doing what’s best for our patients. Use the Sheehan Disability Scale to measure functioning in work, family, social lives, and changes with treatment.
Providers should follow up; caregivers can help
It’s a fact that health care providers are stressed and time-pressed. But as health care professionals, we need to be sure that we’re addressing risks appropriately. For example, for teens through mid-20s, there is an increased risk of suicidality and uncomfortable physical activation for those taking SSRIs. This doesn’t mean the SSRIs can’t be used, but it does mean that the provider should work with the family or others close to the person living with depression to be sure they know what to look for and what to do if they have concerns. It also means the provider needs to be clear with the person that they should be in touch if any symptoms are getting worse. And it’s on the provider to follow up with the patient sooner than if they were prescribing for a person older than 24 years or in psychotherapy rather than taking medications. Providers can’t assume that a patient will come back or contact you on their own. It’s a treatment plan, so be systematic in your care.
In our practice, we require patients to come back in four weeks for a follow-up appointment. This saves time in the long run – if treatment isn’t working or is making things worse, we should know about it and decide whether to make changes – and it’s infinitely better for the people affected and for society. Our goal is remission. We want people to be well, productive, living full lives, and contributing to society. People with untreated depression are not likely to be among them.
Anita H. Clayton, M.D., is the David C. Wilson Professor of Psychiatry, Chair of Psychiatry & Neurobehavioral Sciences, and Professor of Clinical Obstetrics & Gynecology at the University of Virginia, Charlottesville, VA. Dr. Clayton has focused her research on major depressive disorder, mood disorders associated with reproductive-life events in women, sexual dysfunction related to illness and medications, and treatment of primary sexual disorders. She has published over 175 peer-reviewed papers, and developed and validated several measurement tools including the Changes in Sexual Functioning Questionnaire (CSFQ), the Sexual Interest and Desire Inventory (SIDI), and the Decreased Sexual Desire Screener (DSDS). She co-edited Women’s Mental Health: A Comprehensive Textbook, and is the author of Satisfaction: Women, Sex, and the Quest for Intimacy for the general public. She has served as President of the International Society for the Study of Women’s Sexual Health (ISSWSH), as Vice-Chair for Women’s Sexual Health for the 3rd and 4th International Consultation on Sexual Medicine in 2009 and 2015, and on the Board of Directors and Scientific Program Committee of the American Society of Clinical Psychopharmacology and ISSWSH.
What do you think?
- What suggestions would you give to a person seeking depression treatment from their primary care provider?
- Changing providers can be logistically and emotionally challenging. What advice can you offer from your experience?
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Additional Reading and Resources
On Care for Your Mind (Depression Treatment series)
- Depression Treatment: It’s About You
- What You Know Affects Treatment
- Response, Remission, Recovery: What Are Your Depression Treatment Goals?
- Why You Deserve Shared Decision Making
- Shared Decision Making – with Families – Yields Better Outcomes
- How to Get the Best, Most Appropriate, Tailored for You Depression Treatment
- How to Address Other Issues in Depression Treatment
- Faster and Easier Approaches for Improving Patients’ Depression Treatment Outcomes
- When Primary Care Providers Treat Depression – Tips for Engagement
- How to Help a Loved One with a Mood Disorder: The FFDA Action Plan
- Does Your Family Know Your Mental Health Care Preferences?
Depression Treatment in Primary Care
- Caregiver Resources from Families for Depression Awareness
- deGruy, F., Treatment of Depression in Primary Care
- Tufts Health Plan, Clinical Guideline for the Treatment of Depression in the Primary Care Setting (download)
- Consultant 360, Major Depression: Treatment in Primary Care
- ICSI Guidelines, Depression, Adult in Primary Care
Screening and Assessment
- SAMHSA-HRSA Center for Integrated Health Solutions
- Hazelden Publishing, Behavioral Health Evolution
- Beidas, R.S., et al., Free, brief, and validated: Standardized instruments for low-resource mental health settings
Wellness and Wellbeing Measurement
- Boston University Center for Psychiatric Rehabilitation, Measuring Mental Health Outcomes
- Wellness Interventions for Life’s Demands (WILD-5 Wellness)
- Lindert, J., et al., Well-being measurement and the WHO health policy Health 2010: systematic review of measurement scales
- Lee Kum Sheung Center for Health and Happiness, Harvard T.H. Chan School of Public Health, Repository of Positive Psychological Well-Being Scales
Care for Your Mind Posts on Medical Leave and Workplace Accommodations
- A Patient’s Guide to Taking Medical Time Off Work
- Depression Costs the Country Billions in Lost Productivity. It’s Time We Started Helping People Get Back to Work
- How to Get What You Need for Workplace Success
- How’s Work Going for You? Your Mental Health Provider Should Be Asking.
- Why Work Matters: Rethinking the Role of Work in Mental Health Treatment
Finally, if you’re interested in what you can reasonably expect from your psychiatrist, check out the American Psychiatric Association Practice Guidelines.