UBC Objectives: Family Medicine, UBC Objectives: Mental Health, & Priority Topic: Depression

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Use a multi-faceted approach to treatment
• Develop appropriate pharmacologic and non-pharmacologic management plans including follow-up for patients with common mental health disorders

Key Feature 4: After a diagnosis of depression is made, look for and diagnose other co-morbid psychiatric conditions (ex: anxiety, bipolar disorder, personality disorder). 
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 5: In a patient diagnosed with depression, treat appropriately:

• Drugs, psychotherapy
• Monitor response to therapy
• Active modification (ex: augmentation, dose changes, drug changes)
• Referral as necessary

Skill: Clinical Reasoning
Phase: Treatment, Follow-up

At this point in my residency, I don't yet have a panel of patients I follow up with regularly. However, because I have a once-weekly callback shift in my home family clinic, I occasionally am lucky enough to be able to follow up with the patients I've seen there previously. Today, on my callback shift, the 19 year old female I previously wrote a previous post about who was having suicidal ideation returned to clinic for her followup appointment. 

I did not delve into the quality of this patient's depression in that last post, but her depression was largely of the seasonal affective variety. For most depressive disorders, first line treatment is antidepressant medication and/or psychotherapy. This major depressive disorder is of a unique subtype, however, in that first line therapy includes light therapy, a totally different modality of treatment. Other first-line recommendations include going for walks outside (even when cloudy), aerobic exercise, and having good sleep hygiene, the latter two of which would probably be useful first-line recommendations for any subtype of depression. See the UpToDate article, Seasonal affective disorder: Treatment (2017), for more information.

This patient was already on a high-dose of an antidepressant and described feeling as though she wasn't getting relief from it (although she had been on it already for 4 years or so, so it was pretty hard to know for sure), I screened her for any other psychiatric symptoms suggesting an alternative diagnosis. She indeed did have anxiety, as she was frequently having panic attacks at night, but she denied ever having elevated or energetic periods in keeping with mania or hypomania, and she denied and on examination did not appear to have any symptoms or signs of psychosis, reducing the likelihood for having disorders associated with this such as schizophrenia or schizoaffective disorder. In my clinical opinion, it seemed as though the anxiety was largely interrelated with the depression, and since the treatment for both depression and anxiety are often similar, this didn't change too much about how we would develop a plan for her treatment.

As this patient was characterised as having suicidal ideation in that previous post, you're probably wondering, just as I was when I saw her name on the dayshift, how she was doing in this regard in followup. At this visit, she was still feeling as depressed as at the last, but she was feeling stable in that her mood was not worsening, and she still did not have any intent of acting on her suicidal thoughts. And again, she didn't think she would feel like she was going to consider acting on her suicidal thoughts anytime in the near future. Phewf. And although her energy was low, at this appointment she was feeling open to giving new therapies a chance - she felt she had nothing to lose at this point. So we went as multi-faceted in our therapeutic approach as I can imagine any disease treatment can get. The plan was as follows:

1. Antidepressant medication 
2. Light therapy
3. Cognitive behavioural therapy
4. Sleep hygiene
5. Aerobic exercise and going for walks
6. Reconnecting with old friends (although not specifically evidence-based, on history I learned that she had fallen out of touch with her closest friends, and I encouraged her to reach out to try to re-establish connections with them)
7. A doctor's note giving her a couple of days off work to give her a bit of respite and get herself organized regarding the above treatment modalities
8. Follow-up appointment in 4 weeks
9. Safety plan for when and how she should return for professional help should she begin to feel acutely worse
10. Consider changing or augmenting medication +/- referral for electroconvulsive therapy in the future if the above interventions are given a good try but turn out not to be sufficient

I wrote out the above list with unchecked boxes in front of each item and gave it to her once we drew up this mutually agreed upon plan. I won't get into the details regarding the specifics of each treatment on that list, but the plan was more nuanced than this of course. For example, we came up with a specific plan that was tailored for her in terms of how she was going to include more aerobic exercise in her life over the next month, and we discussed strategies that she could use to promote good sleep hygiene. And they were all agreed upon in in keeping with SMART goal criteria (specific, measurable, achievable, realistic, timely). You may be thinking that this is an extensive to do list for anyone to followup on, let alone someone who is feeling depressed with all of the demotivation that can come along with that. Certainly it is. However, she was already on a high dose of an antidepressant and using light therapy optimally (so she was simply continuing as usual with these two therapies). She also had a previous positive experience with psychotherapy in the past, so the idea of this option was well-received. 

I would love to know how she is doing at her 4 week follow-up appointment, and if the stars align, I may be in clinic that day to reassess. Until then, it has been a great reminder of the ways in which I can incorporate a multifaceted approach to treatment of illness and restoration of function.