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Thu 28 Feb 2008 04:00 AM

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Treating depression

Forget the hunt for a magic pill. Effective treatment requires time, attention, and unbiased information.

According to the World Health Organization, at least 121 million people worldwide have depression, a common mental disorder characterized by depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration.

In some patients, these problems can become chronic or recurrent and lead to substantial functional impairments or even suicide.

While drug therapy targets blood pressure, the benefits of positive lifestyle changes reverberate throughout the body.

While depression can be reliably diagnosed and treated in the primary care setting, patients often fail to get the care they need.

There are many reasons for this failure. Among them is a lack of resources, lack of trained providers and the social stigma depression can carry.

There is also a great deal of confusion surrounding the cause and treatment of depression, says Dr. John Abramson, a family physician who is also a clinical instructor at Harvard Medical School and author of a book called Overdosed America: The Broken Promise of American Medicine (HarperCollins, 2004).

The prevailing trend, which is fueled by pharmaceutical industry-funded research, he says, is to think of depression as a biomedical illness rather than a "disordered relationship between a person and his or her environment and the emotional consequences of that disorder"-which is often sadness.

"We've seen a series of theories about the biomedical cause of depression as new generations of drugs have been approved and patented," Abramson explains. At first MAOI inhibitors were in vogue.

Then it was tricyclic antidepressants. Now its selective serotonin reuptake inhibitors (SSRIs), and soon it will be something else. "Each generation of drugs has brought with it a theory, but one could argue that these theories are retrofitted to the available drugs and face a predictable lifespan based on the lifespan of the patents on the drugs."

As a result, many patients who present with symptoms of depression that are less severe than is diagnosed as "major depressive disorder" (based on the criteria in DSM IV) receive the most popular antidepressant medication rather than receiving a course in psychotherapy, which is shown to be more effective in the long term.

At best, 60% of those treated with antidepressants alleviate symptoms of major depressive disorder, compared with about 50% of those who take a placebo. And about 70% of people who successfully recover from major depression can expect it to recur.

Furthermore, many patients who take antidepressants develop side effects, which can include loss of libido, weight gain, akathesia (overwhelming inner restlessness), and suicidal thoughts.

And when patients with less than major depression are given drugs instead of counseling, says Abramson, they face the "disempowerment of being told they have a physical illness when they might well have symptoms that are a consequence of what's going on in their lives."

Physicians need improvement

To be sure, a complex array of factors makes mental health care in the primary setting difficult. Oftentimes patients are reluctant to discuss their symptoms, either out of shame or embarrassment.

And many physicians fail to observe their patients' symptoms because they haven't received adequate training, don't have access to reliable unbiased information, or are uncomfortable discussing emotional issues.

A survey of 90 general practitioners in Abu Dhabi, published in the January 2006 Middle East Journal of Family Medicine, revealed that the vast majority lack adequate knowledge about anxiety and depression.

While over 80% felt competent in diagnosing anxiety and depression, they said they were more comfortable treating physical illness. Nearly three-quarters said they did not have enough time to explore psychological issues during the consultation, and only half answered a series of questions on depression correctly.

Similar findings have been reported in the U.S. where a September 2007 study by the Rand Corp. showed that most primary care physicians do a poor job of monitoring depressed patients beyond a period of a few months, are unlikely to recommend consultation with a mental health specialist, and often fail to adjust medication or dosage for patients whose symptoms get worse.

Clearing the hurdles

Given the widespread challenges and conflicting information, one may ask whether it is even possible to effectively treat depression in the primary care setting.

Studies show that it is. According to the WHO, primary care-based quality improvement programs can improve patients' quality of care, satisfaction, health outcomes, functioning, economic productivity, and even household wealth.

But what is the individual practitioner's role? To begin with, says Abramson, physicians should read the medical literature with a skeptical eye, recognising that "most of today's medical clinical research is funded by commercial interests."

Second they should seek alternative sources of information.
Third, it is essential to separate Major Depression from its lesser forms.

The DSM IV defines Major Depressive Disorder as having at least one Major Depressive Episode that is not better accounted for by another form of mental illness, such as schizophrenia, and does not follow a Manic, Mixed, or Hypomanic Episode.

To make the diagnosis of Major Depressive Disorder, a patient needs to have had depressed mood most of the day or markedly diminished interest or pleasure in all, or almost all, activities, plus at least four of the following symptoms nearly every day or daily during the same two-week period:

• Significant changes in weight or appetite

• Insomnia or hypersomnia

• Objectively observable psychomotor agitation or retardation

• Fatigue or loss of energy

• Feelings of worthlessness or excessive or inappropriate guilt

• Diminished ability to think or concentrate, or indecisiveness

• Recurrent suicidal thoughts, a suicide attempt, or a specific plan for committing suicide

In addition, the symptoms must represent a change from previous functioning and cause clinically significant distress or impaired daily functioning.

They must not be related to the loss of a loved one (bereavement), substance abuse, or a general medical condition such as hypothyroidism.

Empowering patients

If a patient does have Major Depression, prescribing antidepressant medication is usually advisable.

But it's important to understand that out of every 10 such patients treated with an antidepressant, only one will experience improvement because they were treated, says Abramson.

"There's an illusion that antidepressants are enormously effective, when in fact they only work 10% better than a placebo."

Drugs are less effective (if they work at all) in patients with minor depression or melancholia, says Abramson. For these patients, physicians should instead ask why the person is feeling sadder than he or she would like to.

"A good general physician will start to explore the patient's family relations, occupational relations, political environment, and economic environment, to discern what is robbing meaning from the patient's life," says Abramson.

The next step is to help the patient identify those problems and take constructive measures to fix them.

Often GPs with the proper training can offer patients short-term psychotherapy consisting of weekly 15-minute visits over a period of six to eight weeks.

Abramson says such therapy can be very effective by "helping patients gain insight into what's making them feel blue and understand what kind of changes can lead to improved relations and mood."

Of course, some patients will have family, economic, or political situations that are intractable. In those cases, "the challenge is to help them adjust to their circumstances, and take steps that will allow them to take constructive action they are now unable to take," says Abramson.

Those with deep-seated problems that require more intensive psychotherapy should be referred to a mental health professional.

The bottom line, says Abramson, is to avoid the temptation to give patients a pill and send them on their way.

Sources of unbiased information

• Therapeutics Initiative, The University of British Columbia: http://www.ti.ubc.ca/

• National Institute for Health and Clinical Excellence: http://www.nice.org.uk/

• Drug Effectiveness Research Program (DERP), Oregon Health & Science University: http://www.ohsu.edu/drugeffectiveness

Depression facts

• Depression is common, affecting about 121 million people worldwide.

• Depression is among the leading causes of disability worldwide.

• Depression can be reliably diagnosed and treated in primary care.

• Fewer than 25 % of those affected have access to effective treatments.

(Source: World Health Organisation)

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