Treatment of depressive illness

Most depressive episodes present in general practice, and quickly resolve with primary care treatment. It is likely that this represents a combination of the natural tendency of such conditions to resolve spontaneously, together with the positive effects of a sympathetic interview, diagnosis, explanation, and reassurance.

The prescription of medication or the use of counselling is also likely be helpful, although in both cases the non-specific effects of treatment ('placebo effects') are likely to be just as, if not more, important than the specific clinical effectiveness of the particular treatment employed.

Only a small percentage of such cases are referred to specialists; a figure of 10 per cent would probably be on the high side. The majority of these are managed as outpatients; some of the more severe cases will be allocated help from the community mental health team, such as a community psychiatric nurse and/or attendance at a day centre.

Hospital admission may be required for patients who are suicidal, or refusing food and drink. Compulsory admission under the Mental Health Act 1983 may be required.

A few cases will need to have ECT (see Chapter 24). ECT is a widely feared treatment, although it is very effective in emergency cases when the patient has stopped eating and drinking properly, and is in danger of death through dehydration. However, modern treatments seem to be increasingly effective, and I prescribe ECT only about once a year or less in my practice. It is now, in effect, either an emergency treatment or a treatment of last resort.

Medication and psychological treatment are thus the main specific therapeutic options. However, usually no individual treatment is 100 per cent effective; a good recovery in a more severe case will often involve two or three therapeutic modalities, such as medication and psychological treatment, each contributing a partial amount, but adding up in combination to an effective treatment package.

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