Patients need close follow-up for treatment of clinical depression.
By Jeanie Lerche Davis
Reviewed By Cynthia Haines
Who prescribed your antidepressant? Not a psychiatrist, most likely.
Up to 80% of antidepressants are prescribed by primary care doctors -- and given the high rate of clinical depression, "that's a good thing," says David Feinberg, MD, a clinical psychiatrist with the UCLA Neuropsychiatric Institute.
In fact, many insurance plans require a primary care doctor be the first step in treatment. "Pediatricians, primary care doctors, and family doctors have always provided a tremendous amount of mental health care," Feinberg tells WebMD. "If they didn't, too much depression would not get treated."
However, the recent FDA warning about antidepressants -- that depression and suicidal thoughts could get worse at certain points in treatment -- concerns many people.
What kind of follow-up care should adults or children get from a primary care doctor? How frequently should they see their doctors? Should patients (or parents) push for more follow-up care? Should a psychiatrist be involved in treatment? Is therapy necessary?
For guidance on these issues, WebMD contacted several psychiatrists. Their advice:
1) Be your own (or your child's) advocate.
Primary care providers can generally diagnose clinical depression in adults. Sadness, difficulty concentrating, sleep problems, lack of energy, and hopelessness are classic symptoms. Discuss them with your doctor, and talk about all the treatment options.
However, with children and adolescents, depression is not so easy to diagnose, says David Fassler, MD, private practice child and adolescent psychiatrist and professor of psychiatry at the University of Vermont.
"Depressed kids don't always look like you would expect," he tells WebMD. "Quite often, they are not sad or withdrawn. They may be irritable, getting into fights, agitated. Getting an accurate diagnosis is key with kids. Some social workers and psychologists are good at recognizing depression in kids, as are some pediatricians and family practice physicians."
A psychiatrist's evaluation is often necessary to determine just what is going on with a child, he says. "Frequently, a child psychiatrist does the initial evaluation and prescribes medication. Then the child is referred back to the pediatrician for monitoring and follow-up, hopefully in conjunction with therapy."
2) Do your homework.
For a short-term episode of clinical depression -- what doctors call mild or moderate depression -- treatment with either medication or therapy alone will usually work, explains Michael Thase, MD, professor of psychiatry at the University of Pittsburgh School of Medicine and author of the book, Beating the Blues.
Both antidepressants and therapy change brain chemistry, which relieves depression and stabilizes mood, research shows. But before making a decision, do some research, advises Feinberg.
"If you're talking about an antidepressant, read everything you can find about it," he says. "Don't allow your child to take an antidepressant that has not been tested and found safe for children."
For most children, antidepressants are prescribed for short-term treatment, although some will need to continue much longer, says Fassler. "Some kids, particularly those with recurrent episodes of depression, may take medications for many years and into adulthood."
3) Discuss the merits of therapy.
Research has shown that a combination treatment -- both medications and therapy -- can prevent recurrences of depression for many years after drug treatment ends. When people take antidepressants alone, they are more vulnerable to depression once they stop the drug.
Therapy helps people understand the roots of their depression, change negative thought patterns, and learn better coping skills, Fassler explains.
Therapy can also help fix emotional problems caused by the depression itself, he says. "By the time patients get help, there are lots of secondary emotional ramifications -- self-esteem problems, guilt about their depression, they feel different, have trouble at school, home, friends. Medication isn't going to fix those problems."
If kids are reluctant to take antidepressants, therapy can provide the encouragement they need, Fassler tells WebMD. "It's a struggle. But if kids really understand what the illness is about, and see how medicine helps them live more normal and healthy lives, they are more likely to take it."
4) Make sure doctors communicate with each other.
If multiple doctors are treating you or your child, make sure they share treatment information, says Fassler.
"Across the country, we're seeing more and more prescriptions for antidepressant medications written by pediatricians and primary care physicians," says Fassler, who is also a spokesman for the American Academy of Child and Adolescent Psychiatry.
"Make sure the various doctors are talking to each other -- so they can see how the child is doing" he tells WebMD. He also says to make sure that the signs of side effects are dealt with right away.
5) Know symptoms of worsening depression.
Doctors will usually see patients at least monthly when they are starting or changing doses of antidepressants, says Thase. "But with the new FDA cautionary statement, follow-up should be more frequent." Telephone check-ins could be set up and may be sufficient.
However, "it's important for patients to know that if they take a turn for the worse, they can see the doctor quickly," he tells WebMD. "If patients notice they're not sleeping well, getting restless, having more negative thoughts, let the doctor know that, so the dosage can be changed. They should not suffer in silence."
Children should get careful monitoring, says Fassler. "Every child's depression is different, and parents have to work with the doctor to figure out what symptoms should be monitored -- whether the child's energy is improving, if they're less irritable, sleeping better, appetite better, doing more things with friends. If any child is expressing thoughts about hurting themselves or anyone else, obviously they need to be seen and re-evaluated."
Talk to the child's doctor about monitoring symptoms, Fassler advises. "During initial phases of treatment, children should be seen more frequently. If the child's behavior has not started to change after a couple of weeks, call the doctor, ask 'What should I do?'"
Some kids will tell their parents about thoughts of suicide, he says. "Some will tell a friend. Usually, if someone's thinking about suicide, they will tell somebody. That's why it's important that they see a doctor frequently, so they can talk about these things."
6) Learn the system.
Managed care companies now recognize the need for mental health treatment, Feinberg tells WebMD. "The number of visits may be limited, but I think managed care has done a good job in increasing access to treatment."
However, there may be some difficulty getting coverage for a psychiatrist's care, he adds. Patients may have to pay out of pocket, or sign up for a preferred provider organization (PPO) plan, to get coverage for a psychiatrist's care.
Privacy should not be an issue, Feinberg emphasizes. Don't be concerned that an employer could find out you are using mental health benefits. "It's against the law for a mental health provider or insurance company to let an employer know you have received mental health services," he says. New federal regulations have reinforced that privacy.
Also, most large employers offer Employee Assistance Programs (EAPs) that provide limited visits -- for adults and family members -- with a mental health professional.
Access to treatment for clinical depression has improved in recent years, Feinberg tells WebMD. "If you need therapy, you will get therapy."
Originally published May 10, 2004.
Medically updated September 2004.
SOURCES: David Feinberg, MD, clinical psychiatrist, UCLA Neuropsychiatric Institute. David Fassler, MD, child and adolescent psychiatrist; professor of psychiatry, University of Vermont. Michael Thase, MD, professor of psychiatry, University of Pittsburgh School of Medicine; author, Beating the Blues. WebMD Medical News: "Drugs May Help Talk Therapy Beat Panic," "Antidepressants May Lower Suicide Risk," "Therapy as Good as Drugs for Depression."
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