Depressed Patients Who Seek Help Usually Respond to Treatment

Although about 21 million Americans suffer depression in any one-year period, only about 1 in 4 seeks medical help for their condition. That's unfortunate, says Thomas W. Heinrich, MD, an Assistant Professor of Psychiatry and Behavioral Medicine at the Medical College of Wisconsin, because more than 80% of patients with depressive disorders respond to therapy.

Therapies and their duration vary by individuals, he says, depending on the symptoms, health history, and severity of disease that patients present or exhibit when they are diagnosed. Therapeutic approaches include an arsenal of drug types, psychotherapy and counseling, and somatic treatments such as electroconvulsive therapy.

Therapies can be prescribed singly or in combination, depending on the diagnosis, although "there's no evidence that a combination of therapies works better than one alone, if it's appropriately chosen," Dr. Heinrich says.

The National Institute of Mental Health (NIMH) says even patients with so-called minor depression should seek treatment, because if their condition persists, it can impair functioning and quality of life, and is a serious risk factor for major depression. Patients with minor depression exhibit some symptoms that are similar to major depression, with either a depressed mood most of the day, nearly every day, or a markedly diminished interest or pleasure in daily activities, plus two to four of the following symptoms:

• Significant weight loss or gain, or decrease or increase in appetite
• Disturbance in sleep pattern
• Noticeable agitation or slowness
• Fatigue or loss of energy
• Inappropriate feelings of worthlessness or guilt
• Diminished ability to concentrate, indecisiveness
• Recurrent thoughts of death or suicide

In many cases, depressed patients are seen initially by their primary-care physician. Yet, not all primary-care doctors have the time or expertise necessary to definitively rule in or rule out depression. To assist them in their initial diagnosis, several screening tools are available for primary-care physicians. Most of these are in the form of brief patient surveys addressing symptoms such as those listed above - questions about mood, enjoyment, and changes in sleep or eating patterns.

Depending on the findings, physicians may begin treatment or refer patients to specialists like Dr. Heinrich.

Diagnosing Depression
In treating all types of depression, a careful diagnosis is key, Dr. Heinrich says.

"A thorough diagnosis involves gathering the patient's history, symptoms, and medical history, with an eye toward looking for potential causes," he says. "It's important to spend time looking for medical conditions or medications that can cause symptoms that may mimic depression, such as thyroid disorders and steroids."

Some drugs and medical conditions can induce irritability, confusional states, mood disturbances (both depression and mania) and psychosis, which could mistakenly be thought of as being caused by a mental illness rather than being a consequence of a medical condition or a side effect of a medication prescribed to treat a medical condition, he adds.

During the diagnostic procedure, the doctor asks about the patient's history, including current symptoms, past psychiatric problems, medical history and current medications (including over-the-counter medications and supplements). The physician may order laboratory tests to rule in or rule out medical conditions that could be contributing to the patient's initial complaints. The diagnosis should also include a thorough mental status examination, Dr. Heinrich says: "While the interview is going on, the doctor observes the patient's appearance, psychomotor activity (such as restlessness, tremor, excessive gesturing or pacing), general mood, speech patterns, and thought processes."

For some patients, the diagnosis is fairly straightforward, and completed within a short period. With others, it might take a series of visits for the physician to definitively diagnose depression and its severity.

New techniques, including the use of functional magnetic resonance imaging, or fMRI, are helping researchers pinpoint which areas of the brain might be affected. Although in its infancy, research into potential genetic markers that may predispose certain individuals to depression is progressing, along with studies of genetic variables that could help determine more effective treatments for depression.

Drug Treatments
Medication is a common approach to treating depression, and more than 80% of patients respond to the right drug, says Dr. Heinrich, adding, however: "Any one medication is effective in only 60% of patients."

That means treating depression often becomes a process of multiple medication trials, as physicians search for the right medication (or combination of medications) to help the patient. Antidepressant medications fall into several primary classes, he says - monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitor (SSRIs) and atypical antidepressants. Some patients will only need to take antidepressants for a short term; others may need to take medications for long periods. (Some of these medications are also used to treat conditions other than depression.)

"It's often hard to convince patients to stick with antidepressant treatment," Dr. Heinrich admits, "especially since improvements in mood can take up to a month to develop, but side effects tend to occur right away."

According to NIMH, antidepressants may cause mild, and usually temporary, side effects (sometimes referred to as adverse effects) in some people. Typically these are annoying, but not serious.

Among newer drugs, the NIMH lists as common side effects such conditions as:

• Temporary headache
• Temporary nausea
• Nervousness and insomnia
• Agitation
• Sexual problems

Physicians must carefully select which drugs to prescribe so they don't interact with any medications patients are already taking. In addition to the drugs' safety and how well patients tolerate them, physicians must also take into account how effective a particular drug or drug class may be, given each patient's medical status. Another consideration is cost, Dr. Heinrich says. Some patients might not be able to afford certain drugs.

Herbals Can Affect Drug Action
Drug interaction is also a factor with certain over-the-counter drugs, including herbals like St. John's wort, which is widely self-prescribed to relieve depression.

"St. John's wort has a confusing reputation," Dr. Heinrich says. "Some European studies have found it effective, but studies done in the United States have shown mixed results. It's not entirely benign, because of its ability to interact with and inhibit the metabolism of other medications."

At the Medical College, a number of drug studies are under way, he notes, including a study of a potential new class of antidepressant drug that affects melatonin, a hormone involved in the wake-sleep cycle and other body functions.

Psychotherapy
Many patients with mild to moderate depression respond well to psychotherapeutic counseling, Dr. Heinrich says. This includes two types of approaches - interpersonal therapy (IPT) and cognitive behavioral therapy (CBT).

With IPT, doctors lead patients through discussions of their feelings and their behavior toward others, often focusing on disturbed personal relationships that both cause and increase their depression.

With CBT, doctors help patients change the negative styles of thinking and behaving often associated with depression. For instance, patients who think or say, "Everyone hates me," or "My life is hopeless," are challenged to justify those beliefs and learn to correct them.

Somatic therapies
One of the most effective treatments for major depression is electroconvulsive therapy (ECT), which has greatly improved in recent years. "It's nothing like the way it was portrayed in 'One Flew Over the Cuckoo's Nest,'" Dr. Heinrich says, referring to the 1975 Academy Award-winning film starring Jack Nicholson as an asylum inmate. "ECT has undergone many improvements over the years. These improvements have resulted in a treatment that is very effective and well tolerated with a low risk of complications."

ECT can be effective for those with severe or life-threatening depression, and for those who cannot take antidepressant medications or fail to find sufficient relief of symptoms with medication. "Despite ECT's great effectiveness and tolerability," he says, "it is likely underused in psychiatric practice today, and too often given the stigma associated with 'shock therapy'."

Family members and friends of people who show signs of depression should help them get appropriate diagnosis and treatment. "Depression is a common medical condition," Dr. Heinrich says, "and it can have a significant negative impact on quality of life and on co-morbid physical health. It's important to note, however, that depression is also highly treatable."

Barbara Abel
HealthLink Contributing Writer

For more information on this topic, see Part 1 of Dr. Heinrich's discussion, Depression Is Not Just Sadness - and It Shouldn't Be Ignored.

Thomas W. Heinrich, MD, practices at Froedtert Hospital, the Medical College of Wisconsin Behavioral Health Center in Tosa Center on Mayfair Road, and Community Memorial Hospital in Menomonee Falls.

This article includes information from the National Institutes of Mental Health.