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MENTAL HEALTH
CHALLENGES

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TREATMENT in medical school, there are certainly no marketing representatives
Approximately 80% of patients with LLD receive their treatment bringing meals to the office touting the benefits of psychotherapy
in a primary care setting, although surveys still show there is still for depression, and also physicians are not used to referring to
significant underdiagnoses. The primary care setting is advanta- LPCs, LMFTs, LCSWs or PhDs.
geous, as it provides continuity of care, access to medical and lab-
oratory testing, and is free of the stigma of psychiatric referral. * Medication
Treatment usually can be considered to be one of three common As in younger patients, the initial treatment choices for depressive
types, although a multi-modal approach with involvement of each illness are the SSRIs, with some concern over fluoxetine because of
type of treatment is often beneficial. its very long half-life. There is also some concern over paroxetine
because of concerns of memory impairment secondary to its anti-

* Environmental cholinergic effects, however this has not been found during objec-
Encouraging or facilitating increased physical activity (physical tive study. Sertraline, citalopram, and escitalopram are most useful,
exercise, walking, attendance at a senior center or gym) is very help- with minimal drug-drug interactions. There is some evidence that
ful, and there is increasing data about the benefit of physical exercise sertraline is especially useful for improving cognition. Other rela-
on depressive illness. Increased socialization is also helpful, whether tively well tolerated antidepressants are venlafaxine, bupropion, du-
at a neighborhood center, local church or with friends and family. loxetine and mirtazapine. Older antidepressants such as tricyclics
Increased involvement of supportive family is very helpful. Not (amitriptyline, nortriptyline) or MAOIs are not considered good
only can they provide support, but also supply important collateral choices, because of possible significant side effects.
history and family history, assistance in accepting and adhering to Current dosing recommendations have not changed from what I
recommended treatment, and assistance in attending important ap- was taught in medical school 50 years ago, “start low and go slow.”
pointments. Improvement of hearing, vision, and nutrition is uni- There is no such thing as the “proper dose,” except as determined
versally recommended. The data now show that proper nutrition is by adequate response in that individual patient. Dosing should be
as important in treating depression as in treating diabetes, hyper- increased every 10-14 days until the patient begins to have some ef-
lipidemia and/or cardiovascular disease. fect (side effects or improvement) and then the dose may be
plateaued to ascertain how much improvement eventually will occur.
* Psychotherapy The goal is to “treat to remission,” and not just to accept improve-
Large-scale meta-analysis shows similar results comparing psy- ment. This leads to better functioning and less relapse. If the patient
chotherapy with medication treatment in depressive illness. How- has not improved after a few months and the dose is approximately
ever, psychotherapy is not recommended frequently enough, twice that of the “average” dose with normal thyroid, B-12, folate,
because of lack of physician familiarity with the benefits, the various and Vitamin D levels, then psychiatric referral is recommended.
methods available, and the lack of familiarity with referral sources. There are numerous choices available when a patient is not improv-
In addition, the value of psychotherapy is not emphasized enough ing, but the subtlety of that is best handled by psychiatrists.

20 San Antonio Medicine • May 2019