Recent Advances in Psychological Depression Treatment in Primary Care

Saleem Ahmad^*
*Correspondence: Saleem Ahmad, Department of Biomedical Sciences, Alagappa University, Karaikudi, Tamil Nadu, India, Email:

Keywords

Major depressive disorder • Depression • primary care • Psychotherapy • Cognitive behaviour therapy • Interpersonal psychotherapy

Introduction

Depressive disorders are highly widespread, incapacitating, and expensive illnesses that are associated with significantly reduced role functioning and quality of life, medical comorbidity, and mortality. Significant advancements have been achieved in the past few decades in the study of depression and the creation of therapies for it in a variety of contexts, including general care. Today, a wide range of antidepressant medications and forms of psychotherapy are accessible and have been proven to be efficient in several randomised trials. Numerous of these treatments are mentioned in treatment guidelines and are frequently employed in clinical settings due to their considerable and favourable outcomes. Only a tiny percentage of depressed individuals are referred to mental health facilities; the majority of depressed patients are treated in general care. Despite the fact that there have been hundreds of randomised trials on medications and therapies, the majority of these studies have not been directed at patients in primary care. However, because depression in primary care patients is generally thought to be less severe, the outcomes for therapies discovered in specialist mental health care may not apply to depressed primary care patients. Although there are no clinically significant differences in the short run between the tiny but favourable effects of antidepressant medication and psychotherapies on depression, many general practitioners (GPs) incline to prescribe antidepressant drugs to depressed patients. However, most patients choose psychological therapies. In a systematic review of 34 studies conducted in various settings, it was discovered that, on average, 75% of patients with mental disorders preferred psychotherapy over drug therapy, particularly in younger patients. However, there are some signs that this may be related to the severity of depression, with more severe patients more frequently favouring drug treatment.

In this article, we will provide an overview of the psychological interventions that are currently accessible and have been put to the test on patients in primary care. We will also look at how different treatments, antidepressants, and their combinations affect people. We will discuss what is known about who can deliver these therapies (individually, in groups, over the phone, online), as well as how they can be delivered. Then, we will concentrate on recent advancements in the field, such as the use of therapies delivered by new technologies, the rise in psychotherapy trials conducted in primary settings in low and middle income countries (LMICs), the recent proof that straightforward forms of therapy are just as effective as more involved ones, the potential importance of treating sub threshold depression as a preventive measure, and the expanding body of knowledge regarding the management of syphilis.

Literature Review

In primary care, various distinct forms of psychotherapy for depression have been created and evaluated over the past few decades. If you want to help people change their behaviours, thoughts, emotions, and/or other personal characteristics in ways that they deem desirable, you can help them by engaging in psychotherapy [1]. Psychotherapy is defined as "the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles." Cognitive behaviour therapy (CBT), behavioural activation therapy (BAT), interpersonal psychotherapy (IPT), problem-solving therapy, and non-directive counselling have all been studied most thoroughly in primary care settings. There is a sizable amount of research showing that psychotherapies are successful in treating depression. Treatments are typically contrasted in randomised trials with care-as-usual, a waiting list, a pill placebo, or other control conditions. The effects are modest to significant when compared to these control situations (Cohen's d values between 0.6 and 0.9). However, publication bias is a significant issue, and the quality of these trials is frequently subpar. When these issues are taken into account, the effect sizes (Cohen's d) are between 0.3 and 0.4, which translates to an NNT of between 8 and 11. There is no proof that the outcomes of various therapies differ considerably from one another. Network meta-analyses and trials that directly compare various therapeutic modalities point to similar outcomes for all main therapeutic modalities. Although the number of studies was small and some differences between IPT and internet-based CBT were discovered, they were based on a small number of studies and were mostly indirect evidence. This finding of no significant differences between therapies is supported by one meta-analysis looking at differential effects of psychotherapies conducted in primary care [2]. Clinical psychologists, trained nurses, social workers, and general practitioners (GPs) can all provide psychotherapies in primary care. Rarely is it investigated whether the results of therapies are related to the person providing the treatment.

In large-scale meta-analyses of randomised trials conducted in various settings, it has been discovered that medications, in addition to psychotherapies, are also useful in the treatment of depression. A moderate, but substantial, effect of medicines on response relative to placebo was discovered in one meta-analysis of 17 antidepressant trials in primary care patients. However, the bulk of these studies were conducted on patients who had moderate to severe depression, whereas the majority of patients have mild to moderate depression. These results must therefore be treated with caution. Additionally, a sizable recent trial in patients with moderate depression in primary care was unable to establish that sertraline was superior to placebo. Psychotherapies have shortterm effects that are equivalent to antidepressants in all contexts. Even when blinding is taken into consideration (when a placebo condition is included), as well as sponsorship bias, direct comparisons between antidepressants and treatments produce minor, non-significant changes. However, there are signs that psychotherapy is superior to medicine for a longer period of time (up to one year), particularly when patients cease taking their prescription during follow-up. The results of CBT without continued treatment during follow-up are comparable when the patient continues to take medication during follow-up [3].

It is obvious that combined treatment is more successful than either psychotherapy or pharmacotherapy used alone, although this has only been studied in patients with moderate to severe depression; it is unclear whether the same is true for milder forms of the disorder. It has been discovered that psychotherapy and combined treatment are more acceptable than antidepressants alone. It has not been determined whether the findings of the majority of the meta-analyses in this area also apply to primary care because they have looked at these problems in various settings.

Delivering psychotherapies remotely via the internet and mobile apps is an intriguing development from recent years. It is becoming more and more obvious that the outcomes of these interventions are on par with those of inperson therapies. There were no discernible differences between face-to-face therapy and the identical intervention that was provided as an internet-based treatment in a recent meta-analysis of trials that examined the two formats. The therapies for a wide spectrum of mental diseases were combined in this meta-analysis, though. A more thorough investigation of the treatment format was conducted in a recent meta-analysis that focused exclusively on depression. In a network meta-analysis of 155 research on CBT for depression, several treatment forms were compared to one another and to various control circumstances. Individual, group, telephone-based, and guided self-help formats did not differ significantly from one another. With the assistance of a qualified therapist, the patient uses guided self-help to progress autonomously through a set protocol. The support from the therapist can be given over the phone, by email, or through chat, and the protocol can be found in book form or online [4]. The effects of these various formats were found to be same in this meta-analysis (including internet-based guided self-help). However, although having effects that were equivalent to those of other treatment formats, guided self-help was found to have a much lower acceptance. Drop-out from the study for any reason was considered acceptable. Clinicians should use caution when using guided self-help with patients to prevent early drop-out [5].

A number of meta-analyses have demonstrated that the effects of various manualized therapy are indeed comparable, answering the question of whether all treatments for depression have effects that are equivalent. This begs the question of whether therapies may be made more straightforward without reducing their effects. Internet-based interventions and task shifting interventions, in which lay health counsellors administer treatments, can both be viewed as examples of this development because they consume significantly fewer resources while producing results that are on par with those of traditional individual therapies. Another advancement in this field is primary care behavioural activation treatment research. The most common form of therapy that has been endorsed as the first line of treatment for depression in most guidelines is CBT. However, it is also rather challenging and calls on individuals to be able to recognise, analyse, and alter their own thought processes. It is more easier and simpler to activate behaviour. In theory, it increases "good interactions between a person and his or her surroundings" and just requires patients to be aware of the enjoyable activities they engage in. Then, they ought to include these enjoyable activities more into their daily lives. The majority of CBT manuals incorporate behavioural activation, but as we saw previously, it can also be used as a stand-alone therapy without cognitive restructuring [6].

Since the 1970s, numerous studies have looked into whether CBT and behavioural activation have similar benefits. However, none of these studies had enough individuals and were severely underpowered to detect even a slight difference between the two. However, a sizable, adequately powered non-inferiority experiment comparing behavioural activation provided by intern mental health professionals to CBT provided by certified psychological therapists for depressed primary care patients was reported in 2016. A noninferiority comparison between CBT and behavioural activation therapy was made. This means that it is equally effective in primary care as CBT, but it is considerably simpler and easier for patients to use, and it may be successfully provided by therapists with less expertise than CBT therapists.

Discussion

The severity of depressive disorders treated in basic care is typically lower than that of disorders treated in specialised mental health care. Many of these disorders are best described as subthreshold depression or minor depression because they do not fit the criteria for severe depressive disorders. They exhibit clinically significant depression symptoms. It is now more obvious than ever that this group can gain from preventative psychological therapies meant to lessen symptoms and delay the onset of serious depression. A recent large randomised study with patients gathered from the community demonstrated that people with subthreshold depression can benefit significantly from a preventive internet-based intervention that combines behavioural activation and problem-solving. When compared to the enhanced care-as-usual control group after the intervention, the treatment group's level of depression symptoms was considerably lower (Cohen's d = 0.69). But more significantly, after 1-year follow-up, there were considerably fewer patients in the treatment group (27%) compared to the control group (41%), with a hazard ratio of 0.59 (95% CI 0.42–0.82; p = 0.002) and a number-needed-to-be-treated of 5.9.

This finding is consistent with those of earlier research, which have shown that short-term psychological therapies can delay the onset of severe depression in persons with subthreshold depression. Those who received a preventative intervention had a considerably lower incidence rate of subthreshold depression than those who did not, according to a metaanalysis of 17 randomised trials in this area. When compared to the control group, the incidence of depressive disorders was 26% lower in the prevention group (incidence rate ratio: 0.74; 95% confidence interval: 0.61–0.90). These studies included a number of primary care-based investigations. This shows that by recommending brief psychological preventive therapies to patients with subthreshold depression or by providing such interventions themselves, general practitioners can play a significant role in the prevention of major depression. It has been suggested that preventive therapies may also be helpful in this target population by a different group of research that have focused on psychosocial interventions for prenatal depression.

Conclusion

We discovered from this review that psychotherapies work well for treating depression in patients receiving regular medical care. The short-term effects are equivalent to those of antidepressant drugs, but the long-term effects are likely to be more beneficial. In comparison to either psychotherapy or medication therapy alone, combined treatment is more efficient. Psychotherapy is more widely accepted and preferred by most patients than pharmaceutical treatment. Therapy may be efficiently offered in a variety of ways, including online ones, it has become obvious in recent years. As demonstrated in an increasing number of studies in LMICs, it can also be provided by qualified lay health counsellors. As demonstrated by current studies contrasting cognitive behaviour therapy and behavioural activation, the therapeutic approach can also be streamlined. The use of psychological therapy as major depression prevention in patients with subthreshold depression is another intriguing recent finding. Finally, a sizable number of studies have demonstrated the efficacy of psychotherapies in the treatment of prenatal depression, individuals with general medical illnesses, and older adults. In those with co-occurring substance use disorders, persistent depression, and children and adolescents, the consequences are probably less severe. Even if psychotherapies are successful in treating depression, it's important to keep in mind that their effects, like those of antidepressant drugs, are still rather minor. Most patients get better while receiving treatment, but many of them would have gotten better even without it. According to estimates, the likelihood of improvement without therapy is approximately one-quarter after three months and fifty percent after a year. A sizeable percentage of patients—roughly 30%—respond to no treatment, which is on the other end of the range.

Acknowledgement

None.

Conflict of Interest

None.

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