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Standard Treatment Protocol for mental health services into the Primary Health Care System

by Public Health Update
There are many types of disorders of mood (emotion) like unipolar depression, bipolar affective disorder, etc. Among them, unipolar depression is a very common presentation in primary health care set-up. For the sake of simplicity, unipolar depression will be referred as depression from this point on. 

Cover Page Standard Treatment Protocol (STP) for Mental Health Services into the Primary Health Care System

Core symptoms
1. Depressed mood for most time of the day for most of the days 
2. Loss of interest or pleasure in previously pleasurable activities 
3. Easy fatigue or decreased energy 
Other features
1. Feelings of guilt 
2. Feelings of worthlessness 
3. Poor attention and concentration 
4. Low confidence and self-esteem 
5. Negative view of the future 
6. Ideas or attempts of suicide 
7. Poor sleep 
8. Poor appetite 
To diagnose a case of depression: At least 2 core symptoms and at least 3 other symptoms need to be present for at least 2 weeks.
Rule out other physical conditions that can mimic symptoms like depression, such as anemia, malnutrition, thyroid disorders, and medication reaction (steroids, Oral Contraceptive Pills, statins, some anti-hypertensives). If any of these are present, manage them first before starting medication for depression. Refer when management for this condition is not possible from the health center. 
Rule out the presence of manic episode in the past. If there are symptoms like extremely expansive, elated or irritable mood, increased activity and extreme talkativeness, flight of ideas, decreased need for sleep, grandiosity, extreme distractibility or reckless behavior for a duration of at least a week, mania should be suspected and the patient should be referred for further management. 

Special considerations
It is very common in general health clinics for patient with depression to present with multiple physical complaints like non-specific aches and pains, dizziness, tingling (jhamjham) sensation of body. Prescription of multi-vitamins without elaborate history taking is not fruitful for the patient.
Depression can also be seen in children and old age population. These cases need to be referred whenever possible as special considerations need to be taken during management. If the symptoms of depression start during pregnancy, within a month of delivery of a child (post-partum depression) or in a lactating mother, they need to be referred for further management. When people are currently exposed to severe adversity (eg. grief), symptoms may be similar to depression, there should be impairment in daily functioning to make a diagnosis of depression. 
Risk of suicide
Risk of suicide needs to be assessed in every person suspected of having mental health issues. It should always be asked when depression is suspected as a large portion of suicide is caused due to underlying depression. It is not true that asking about suicide initiates a person to commit suicide. Always ask about suicidal ideas/thoughts, plan or previous suicide attempts. Inform family members about risk of suicide and ask for close monitoring of the patient, including removal of harmful objects. Serious risk of suicide is an indication for admission, so refer to a hospital with psychiatric care.

Management of depression
Note: Re-confirm that there is no past history of mania before starting antidepressants Management with antidepressants (SSRI- Selective Serotonin Reuptake inhibitor)
Capsule Fluoxetine 10 mg should be started in the morning, after food and increased to 20 mg after a week. Evaluate after 6 weeks and continue same dose if symptom of depression start decreasing. If there is no change in the symptoms even after 6 weeks, patient should be referred.
For MBBS doctors
Dose of Fluoxetine can be gradually increased by 10 mg every 6 weeks for a maximum up to 40 mg. It is important to wait for 6 weeks at every dose to assess the effectiveness of the dose. Refer if treatment seems ineffective even at 40 mg/day. 
  • When insomnia or severe restlessness is present: Add Tab. Diazepam 5mg PO HS along with fluoxetine. Decrease the dose to 2.5mg after 1 week and then stop Diazepam within 2 weeks. Do not give diazepam for more than 2 weeks.
  • Stop the medication and refer whenever there are symptoms of mania. 
Total duration of treatment: Medication should be given for 9 more months after the symptoms improve significantly. Decrease the dose by 10 mg every 4 weeks and stop the medication. If symptoms restart, refer.
Side effects of Fluoxetine
Common Side effects Restlessness, nervousness, insomnia, anorexia gastrointestinal disturbances, headache, sexual dysfunction 
Serious side –effects marked / prolonged akathisia , bleeding abnormalities in those who regularly use aspirin and other non-steroidal anti-inflammatory drug Refer in case of prolonged or serious side-effects. 
Psychosocial management

If symptoms are present but not enough to make a diagnosis of depression, psychosocial support itself may be enough for treatment. Even when medications are started, psychosocial support needs to be provided to the patient. Advice to patient and family members relating to depression: 
1. Symptoms of depression are not a result of patient’s laziness or lack of effort. It is a disease and the symptoms cannot be controlled by patient’s will-power. 
2. Mention of suicidal ideation should always be taken seriously and immediately followed up. 
3. Patient should be encouraged to continue regular sleep routine and physical activity routine. 
4. Patient should also be encouraged to take part in activities that they used to enjoy even if they do not currently do so. 
5. Treatment is effective in most of the patients, but will take a few weeks to show the desired effects. 
6. Ensure the intake of medications 

Addressing the current psychosocial stressors
1. Provide the opportunity for the patient to talk about their current stressors. Ask them about their understanding of the cause of the stressors. 
2. If there are issues of abuse, contact local centers/ resources to try to manage it. 
3. Help the patient to cope with the current stressors. Involve the support system that the patient already has, such as- friends, family or local groups. 
4. Encourage moderate physical activity (Example: 45 minute walk, 3 times a week). Find out the daily activity of the patient and advice physical activity accordingly. It can be started with shorter duration of activity which can gradually be increased. 
Source: Standard Treatment Protocol (STP) for Mental Health Services into the Primary Health Care System

Depression: let’s talk – 7 April 2017 | World Health Day
Depression: let’s talk – 7 April 2017 | World Health Day
Depression: let’s talk – 7 April 2017 | World Health Day

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