The faculty Eva Trillo and Blanca Fernandez-Abascal.
The Primary Care It is the main gateway to the health system in our country. Consultations for depression maintain a high presence at this level of care, so the training of these health professionals remains crucial. We spoke with Eva Trillo, specialist in Family and Community Medicinemedical coordinator of the Campo de Belchite Health Center (Zaragoza) and member of the board of directors of Semergen Aragón, and Blanca Fernandez-Abascalpsychiatrist at the López Albo I Mental Health Unit, of the Marqués de Valdecilla University Hospital (Santander), on the challenges in the therapeutic approach to depression in Primary Education, as a result of his participation in the training course “Depression 360. Keys to depression in Primary Care”organized by The Butterflies Healthcare, with the sponsorship of Lundbeck and the scientific endorsement of Semergen.
The underdiagnosis of depression in Primary Care continues to be one of the main challenges to be addressed. As Eva Trillo explains, “Only 50% of patients with depression are diagnosed in our Primary Care consultations. This is due to various factors, such as the complexity of the depressive clinical picture, the lack of time with oversaturated schedules, the stigma that still haunts mental health or the lack of training and awareness in this field”.
To advance and improve, both in the prevention and in the diagnosis and treatment of depression, the medical coordinator of the Campo de Belchite Health Center believes that more and better resources are necessary, such as “better training and visibility of the disease, prevention from an early age, coordination between care levels and, above all, time to dedicate to our patients. Obviously, all this requires financial investment and the involvement of the administration”.
With an increasingly aging population, and the high prevalence rates of depression among the elderly, Primary professionals demand specific training to deal with the pathology in this age group. “Depression presents itself differently in each life cycle. The older ones usually present more somatic symptoms. In addition, various pathologies associated with aging concur at these ages that make the diagnosis of depression difficult, delaying treatment and, therefore, worsening the prognosis and with the risk of chronification. And this situation, in turn, will worsen the management and prognosis of their physical pathologies, entering a very complex vicious circle”details Trillo.
On the other hand, managing the disease from a gender perspective is another current need. For the specialist in family medicine, “Women suffer more depression than men due to multiple factors, such as genetics, hormonal, social or behavioral conditions., among others. Each change within the life cycle supposes a stressor that favors its appearance: adolescence, pregnancy and birth of children, climacteric and old age. So, it is interesting to address its management from a gender perspective, as is already done in other pathologies”.
Individualized antidepressant treatment
Faced with the need to that the PC professional can choose the best treatment for each patient, Fernández-Abascal emphasizes personalized treatment. In her opinion, “there is a wide range of antidepressants whose therapeutic efficacy is clearly established in all degrees of depressive disorderso that the choice of the same has to be made on an individual basis”.
To do this, it recommends taking into account a number of factors, such as the predominant symptomatology, age, sex, the presence of both physical and mental comorbidities, concomitant treatmentsthe side effects of the antidepressant, as well as the existence of a previous history of response to antidepressants in previous depressive episodes, both presented by the patient and by a close relative.
The psychiatrist at the Marqués de Valdecilla Hospital recalls that “The goal of treating depression is not only to achieve complete remission of symptoms but also to restore the functionality of the person”. Therefore, when there is no response to treatment or it is partial, some factors must be taken into account, such as “reviewing the patient’s diagnosis and confirming if he really has depression, assessing whether there is any comorbid disease that we are not treating, evaluating compliance with psychopharmacological treatment, since this is one of the most frequent causes of lack of clinical response to antidepressantsrule out taking toxic substances and identify if there was any stressful life event that is acting as a factor that maintains depressive symptoms”, clarifies the doctor.
Once these circumstances have been ruled out, How to act from Primary? “In the event of a total absence of response, it is advisable to switch to another antidepressant, whereas, if the response is partial and the latency time has elapsed, the dose can be optimized of the antidepressant that we are using, or change it or even associate it with an enhancing drug”, explains Fernández-Abascal.
Adverse effects affect compliance with antidepressant treatment. According to this psychiatrist, “those that have the most influence on therapeutic abandonment are weight, sexual dysfunction and sedation. However, other factors also influence poor patient adherence, such as erroneous beliefs regarding side effects or the conviction that he does not need medication. Good adherence is closely related to being able to obtain a complete remission and, therefore, better functioning with a higher quality of life, in addition to preventing relapses”.
Coordination between Primary Care and Mental Health
In the words of Fernández-Abascal, “The coordination of primary care with mental health is the basis for success in the treatment of depression. This will allow a continuity of patient care and a multidisciplinary approach. Let us not forget that primary care physicians have a longitudinal view of the patient that places them in a privileged position to identify any factor that might be precipitating a depressive episode or contributing to a partial response to prescribed antidepressant treatment.
Lastly, the psychiatrist insists on the criteria for referring a patient with depression from PC to Mental Health, which go through “the presence of autolytic risk, diagnosis of bipolar depression, presence of psychotic symptoms and lack of response to two antidepressants at the appropriate dose and time”.
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