Follows from Section 31 on Map 4

We are showing medication as adjunctive treatment, because the evidence seems to be that medication alone is less effective in the long-term treatment of any depression than medication in combination with psychotherapy. With some forms of depression, such as major depression, medication alone is less effective than psychotherapy alone.

39a. After Hospitalization

Commonly the function of a hospital is to stabilize a patient and release him/her to less acute care. Part of stabilizing the patient may include starting him/her on some medication that will need to be continued.

If the hospital has made provision for an outside physician to continue to manage the patient’s medication, you may want to support that recommendation. Otherwise, you need to make your own recommendation to the patient.

39b. As Part of Your Treatment

Issues around a referral for antidepressant medication:

• Indications for medication
• Contraindications
• Cautions
• Expectations
• Choices among medications

39c. When to Refer
Refer when…

• when there are biological indicators
• when the patient agrees
• when the patient understands that you will be in touch with the physician and what the physician needs to know

INDICATORS OF A BIOLOGICALLY-BASED DEPRESSION

These are all important, but there is no way to quantify the indicators. The more there are, the more likely that antidepressants can help the patient, and the better idea it is to refer.

• daily mood fluctuations – generally, feeling better later in the day
• sleep disturbance, either [a] frequent awakenings during the night or waking early in the morning and not being able to return to sleep; or [b] excessive sleeping
• increased or decreased appetite and corresponding weight change
• decreased sex drive
• poor concentration
• forgetfulness
• fatigue
• change in activity: either [a] restlessness, or [b] slowness and listlessness

39d. Whom to Refer to

Ordinarily, medication must be arranged through a psychiatrist or the patient’s family physician.
The family physician should be the one to prescribe if
―the patient has already received medication from his/her physician, and you feel constrained by their choice
―the patient refuses to see a psychiatrist and you believe that some medication (such as a hypnotic or anxiolytic) is needed immediately

More often, however, we refer to a psychiatrist because of their greater training and experience specific to psychotropic medications.

39d. What to Tell the Physician or Psychiatrist
If you have information about the patient, it can be helpful to pass on…
―enough information to orient him/her to the case
―possible indicators of the need for medication; especially biological symptoms
―possible contraindicators, including use of alcohol or recreational drugs, especially information that the patient might be reluctant to tell the physician
―prior depressions
―medications that have been effective in the past
―any manic or hypomanic periods
―any evidence of psychosis
―risk of suicide

39e. What to Tell the Patient

Patients referred for antidepressants should be warned that, when they are effective they often take several weeks, and that the patient should expect to feel somewhat worse first, because of side effects.

Patients should be warned not to expect miracles. There may be some improvement in mood and energy level, but the drug should be considered a temporary help while the patient works on making changes. Even so, antidepressants must be taken consistently, usually for 6 months to two years, and long term maintenance doses are sometimes necessary.

Bipolar patients can expect more immediate relief, when the medication is effective, but may have to remain on the medication for the rest of their lives. Many patients are unhappy with the effects of medication (especially: they may feel strong and effective in a manic state and hate the slowing down of their thought processes from lithium) and wish to stop taking it.

Patients should be encouraged to report any dissatisfaction with medication to their prescribing physician, so that it can be properly adjusted, rather than changing it on their own.