Newly diagnosed hypertension and depressive symptoms: How would you treat?

This case illustrates several important points in the management of depressive symptoms in the family practice setting.

First, patients may present with subsyndromal depressive illness; there is, as yet, no evidence that antidepressants are beneficial in this population, and they expose patients to side effects such as sexual dysfunction.

Second, practitioners in general should not shy away from using beta-blockers where indicated for patients with cardiovascular disease and depression; the link between beta-blockers and depression seems minimal at best.

Third, when patients do present with the syndrome of major depression, it is important to evaluate potential medical contributors (eg, obstructive sleep apnea) when appropriate, and to treat with adequate doses of antidepressants for an adequate duration.

Fourth, the potential effects of depression on the development of CAD give family physicians yet another reason to remain vigilant for the presence of depression in all patients.

Should the FP treat independently? This discussion then leads to the question of when an informal or formal psychiatric consultation is indicated for the treatment of a depressed patient, and when the FP may wish to handle the case independently. The short answer is, of course, “it depends.” As with all areas of medical specialty, FPs will have varying levels of comfort, knowledge, and experience in the treatment of psychiatric disorders, and this will often affect the threshold for obtaining consultation. Furthermore, the number of psychiatric consultants—and thus the opportunity for consultations—varies widely depending on practice location.

Value of informal consultations. In general, FPs are well-equipped to handle patients with uncomplicated major depressive disorder or dysthymia without suicidal ideation or psychotic features. Informal consultation may be useful in cases (as in this case) when it is difficult to distinguish whether the patient meets criteria for major depressive disorder (and therefore requires treatment) or has subthreshold depressive symptoms. In addition, informal consultation can be useful when there is a question about antidepressant agent selection in a specific clinical situation. Finally, informal consultation may be of benefit when there are comorbid psychiatric illnesses, for example, coexisting panic disorder, generalized anxiety disorder, and major depressive disorder.

Opting for formal consultation. Formal psychiatric consultation is often useful when there is a mood disorder with suicidal ideation or psychotic features, when the disorder has been refractory to 2 or more adequate trials of an antidepressant, when there is a question of bipolar disorder (for which monotherapy with antidepressants is contraindicated) or substance use disorder, or for progressively worsening depression despite treatment.

Billing and coding. The logistics of billing for the treatment of comorbid psychiatric disorders by primary care physicians vary with the type of payer and from state to state. Because it is often impractical to modify billing procedures with each patient, it is useful for each practice to develop general billing guidelines for psychiatric disorders billed to Medicaid, Medicare, and the most common managed care organizations in the practice. In general, the physician caring for the patient described in this report would bill for hypertension and depression and get paid under the primary diagnosis of hypertension. When in doubt about whether to bill for a psychiatric disorder, primary care clinicians may include the relevant physical symptom in the billing codes, such as fatigue, headache, insomnia and bill under that code.