A good doctor-patient relationship is key to early diagnosis and adherence to treatment in people suffering from a depressive disorder.

However, the average time available for each consultation from Primary Care in Spain is 7 minutes1, which makes it difficult to establish a therapeutic relationship that facilitates correct diagnosis.

Servier Spain provides psychiatrists and family physicians with its “Manual for the management of depression in the health crisis setting”.

Only half of the patients with depression are diagnosed in the Primary Care consultation due to the complexity of the depressive process, added to the lack of time.

This is one of the data that can be extracted from the ‘Manual for the management of depression in the context of the healthcare crisis’, promoted by Servier Spain, with the aim of offering healthcare professionals a guide to improve the management of depression in this difficult crisis environment resulting from the pandemic. According to Dr. José Ángel Alcalá, a psychiatrist at the Reina Sofía University Hospital in Córdoba and one of the nine coordinators of the manual, one of the main challenges facing primary care is precisely to increase the detection of cases of depression, since “on numerous occasions, the family physician knows the personal biographical history and the social and family context of the patient”.

However, family physicians face a major obstacle: they have an average of seven minutes to see each patient1. 1 This can limit the options for exploring emotions from the clinical point of view, since the diagnosis of depression depends on the information that patients provide to physicians during the consultation. In this regard, Dr. José Manuel Montes, head of the Psychiatry Section at the Ramón y Cajal University Hospital, associate professor at the University of Alcalá and another of the coordinators of the manual that has just been published by Servier Spain, points out that a good doctor-patient relationship is essential: “Depression has many symptoms that are sometimes incomprehensible even to the patient himself. Without this bond of trust, they will not transmit them in seven minutes or seven hours.

One of the obstacles that hinder communication in the consultation room is the idea that still persists of an ambulatory care model in which the physician imposes his or her criteria on the patient. However, according to Dr. Montes, “there has been a paradigm shift and now this has completely disappeared. “Today, there is a relationship of equality in which the physician is an expert, but the patient is also a specialist in his or her own disease, in the sense that he or she is the one who suffers from it. Moreover, this link will have an impact on adherence to treatment: “If the patient does not trust the prescriber, in the best of cases he will start taking his medication, but will soon lose strength and abandon it.

will soon lose strength and abandon it,” warns Dr. Montes.

The importance of Primary Care for mental health

As the gateway to the healthcare system, primary care occupies a strategic position when it comes to identifying patients in need of specialized mental health care. So much so that approximately 80% of psychiatric patients with depression or other mental disorders come from Primary Care2. Dr. Alcalá considers that it is essential to “remember the importance of coordinating patient care within the healthcare system”, as well as “an adequate guarantee of the care received”.

However, the work overload at the first level of care and the long waits between patient referral and specialized consultation call into question the quality of care received by patients with depression. That is why Dr. Alcalá considers it of great importance to improve the fluidity in the interrelationship between Primary Care and Mental Health, as well as to enhance the presence of psychology in health centers.

The traces of the pandemic in mental health care

Outpatient care is biopsychosocial in nature. Difficult access to medical care, together with the implementation of telemedicine models, has complicated the doctor-patient relationship.

This has meant that those patients who were healthy prior to the pandemic and who have developed an illness in the last two years may have experienced communication gaps with healthcare professionals. This distance “has prevented the detection and follow-up of many physical and mental illnesses. It has been a real catastrophe, and we are seeing the consequences,” laments Dr. Montes.

In this sense, the traces of the pandemic “have been seen, mainly, in child and adolescent mental health problems. Since 2017, mental disorders among children aged 4 to 14 years have been increasing considerably, but have done so especially in the last two years,” says Dr. Alcalá, who stresses the importance of “prevention and early identification of symptoms in this population.”

In Dr. Alcalá’s words, the health crisis has also “made clear the existence of gender inequality, since women have suffered numerous situations of vulnerability to suffer mental health problems during the pandemic”; and “there have been numerous risk factors for the worsening of mood in the elderly population due to the change in habits, isolation or the interruption of the usual rhythm of medical consultations”.

“Really, the pandemic cycle has not yet been fully closed, as we are still just coming out of the sixth wave. For example, we are seeing a threefold increase in the number of patients with mental disorders coming to the emergency department. Therefore, it is very likely that the number of patients with depression or another mental disorder will continue to increase,” Dr. Montes concludes in this regard.

As for the risk of suicide, Dr. Alcalá points out that the primary care physician should be aware of “sociodemographic and psychosocial factors, as well as favorable or unfavorable clinical factors. For example, there may be a greater risk of completed suicide in the case of men over 45 years of age, divorced or widowed, unemployed and with associated mental disorders, such as depression, schizophrenia or alcoholism”.

Strategies for the detection of depression

For all these reasons, the ‘Manual for the management of depression in the context of a health crisis’ offers psychiatrists and primary care physicians “the possibility of having teaching material on depression and its treatment, and on how to deal with the consequences of the health crisis in the best possible way, favoring communication with the patient despite the difficulties, by means of telemedicine,” explains Dr. Montes.

For his part, Dr. Alcalá points out that this guide can help the family physician to “improve the early detection of depressive symptoms and acquire interview skills for the assessment of the patient with depression”, in addition to “improving knowledge of the diagnostic criteria and the pharmacological treatment of depression”, as well as “improving knowledge of the diagnostic criteria and pharmacological treatment of depression”.