Managing Depression in General Practice in Pakistan

downloadMajor depressive disorder has been found to be present in nearly 13% of
patients aged over 15 attending general practitioners (GPs) for a new inception of illness3
Comparative
data is not available for Pakistan. However4
two studies that looked into pathways to care in
Rawalpindi and Lahore5
suggest that around 25% of patients seen in a psychiatric service are first seen
by a primaiy health care physician. Other studies done at general practice level6
and a hospital based
non-speciality clinic7
report a widely varying prevalence figure of 5.4-38.4% for anxiety and
depressive syndromes. These syndromes, which form the bulk of psychiatric morbidity in general
practice, had a prevalence figureofmorethan 30% in two recent community surveys, one in Chitral, a
remote rural area in North Pakistan8
and the other in Azam Basti, a Katchi Abadi in Karachi
(Unpublished data). Epidemiological studies from the UK and USA show that the prevalence of major
depression in general population is around 5%9,10. Extrapolation of this data would suggest that there
are more than 42 million anxious and depressed patients amongst Pakistan’s projected population of
140 million11. Atleast 7 million of these suffer from major depressive disorder. This is further
corroborated by the data on consumption of benzodiazepines and antidepressants in Pakistan.
Approximately, 11 million units of benzodiazepine compounds and over 2 million units of
antidepressants were dispensed in the year upto June 1996. Considering that many depressed patients
are inappropriately treated with benzodiazepines, this suggests a large number of patients already
recognized and being treated with medication. With the total number of psychiatrists estimated at 200,
a vast majority of these patients inevitably will be seen and treated by the GPs. It is therefore, important
that initiatives being taken to enhance GPs’ skills to manage depressive illness must get maximum
support.
In the UK, GPs and psychiatrists have developed considerable expertise in this area over the past 50
years. There are many lessons that can be learnt from their success. Firstly, 90% of the depressed
patients are diagnosed and treated by a GP with only 10% being referred to a psychiatrist12. This
implies dissimilarities in the nature of clinical syndromes that present to these different groups of
doctors. Secondly, processes have been developed which GPs can follow to identify depression and
decide upon its management13,14. Skills taught to GPs have been shown to be maintained overtime and
to have an impact on satisfaction and outcome of patient care. However, two interventions, didactic
lectures to GPs by psychiatrists and psychiatrists seeing patients in general practice, do not seem to
improve this process, although they produce other kinds of benefits12. Thirdly, a number of studies
have shown that Research Diagnostic Criteria (RDC)15 are helpful in predicting outcome of treatment
in primary health care setting. Patients respond to antidepressive medication, irrespective of any
precipitating factor, whentheir symptoms fulfill criteria for RDC probable or definite major depressive
episode. And lastly, a tricyclic dose of 150-175 mg daily, or equivalent, is needed for a favourable
response to treatment12. In a recent study set in 41 general practices in London16 benefits from
amitriptyline followed a schedule of drug administration aimed at achieving an intake of 75 mg daily
by the end of the first week, 100 mg daily for the second week and 125 rug or 175 mg daily, if judged
clinically necessary for the last four weeks of the study. At four weeks, the mean daily dose was 119mg
and the median 125 mg. Other research work suggests that therapeutic doses of medication need to
continue for atleast 4 months17, preferably six months18 after recovery to avoid an early relapse.
Attempts have been made to replace the need for GPs to have a high degree of sensitivity to cues of
emotional disturbance by providing them with the results of screening questionnaires applied in the
waiting room19. A number of validated screening instruments in Urdu language have become available
over the past few years. These include the Hospital Anxiety and Depression Scale (HADS)20. Bradford
Somatic Inventozy (BSJ)21, Self Report Questionnaire (SRQ)22, the Aga Khan University Anxiety and
Depression Scale (AKUADS) (Unpublished data) and the General Health Questionnaire (GHQ) 28-
item version (Unpublished data). The AKUADS is particularly unique among these for having been
based entirely on presenting complaints of indigenous patients in Urdu language. The use of screening
instruments, which rely upon the presence or absence of a selection from a constellation of symptoms,
reduces the problems of ‘caseness’ and supplies the GP with a response set of suitable questions to be
trigered by a depression ‘cue’ in exactly the same mainner as the cue word ‘pain’ triggers a response set
in all medically-trained people. On the other hand, such screening instruments cannot replace the skills
of a good physician. A good GP has sensitive ‘antennae’ for various problems he deals with and ought
to have similar sensitivity towards depressive illness. The skill cannot be replaced by a questionnaire.
The focus of GP training therefore, must be his skill to pick up and identify any available ‘cue’ to
depression which may appear anywhere in a consultation. Once a cue has been identified, assessment is
necessaiy to establish as soon as is feasible the probability of the patient suffering from a depressive
illness. This entails not only exploring the sufferer’s experience but also excluding, or identifying and
treating, any of a range of physical conditions which may be linked to the depression. If a depressive
illness is recognized, the GP needs to acknowledge it to the patient in a non-threatening manner which
conveys some hope. This should be followed by an explanation of depression as a syndrome ratherthan
a single symptom ornormal mood which rnjght be treated by the sufferer showing ‘strong will power’.
‘Only after this sequence has been implemented should management be decided upon. Perhaps because
of its difficulty, depressive illness is among the most rewarding diagnoses which a GP can make. Much
of general practice consists of conditions which are self-limiting, though acute, or conditions with an
inevitable downhill progression towards chronic handicap and disability. The successful management
of depressive disorder can produce relief which can be dramatic and rewarding because the patient’s
return to reasonable cognitive function and emotional drive allows the taking and implementation of
decisions which can improve social performance as well as family and working life23
.
It is encouraging to note that a national group of psychiatrists has been active for past few years in
developing training packages for GPs in Pakistan. In a recent meeting of this group (One Day
Workshop of the National Group on Awareness and Prevention of Depression, 4th October, 1996)
material forcontinued medical education has been delineated. It is hoped that these efforts will be
guided by many useful lessons learnt elsewhere in the world. There is a strong need to involve GPs in
this process and review the education material from their perspective. In time general practice will
generate its own criteria and response set for diagnosing and managing depressive disorders. After all,
even the RDC definition of major depression includes key symptoms such as changes in appetite and
sleep and easy fatiguability which canjust as well be produced by organic disease as by affective
disorder. Many GPs do a superb job in the diagnosis and treatment of depression. If all perfonned at the
level of the most accurate, a large number of people would function better and more happily

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