MEDICAL MATTERS:Less need to rely on drugs for depression, writes MUIRIS HOUSTON
THE PENDULUM of opinion as to how doctors treat depression has swung wildly in the past 15 years or so. At first it was a case of under-identifying the disease; now we are accused of overtreating people with depression and being overly flúirseach with prescriptions.
As with most things in life, the truth probably lies some distance from both extremes. It’s certainly become easier to treat depression pharmacologically – the newer SSRI drugs are undoubtedly less dangerous in overdose than previous drug options. But the lack of talking therapies in the public health service has also meant doctors were unable to refer their patients for cognitive behavioural therapy (CBT), the treatment of choice for people with mild depression.
So it is good to report that a joint working party of the College of Psychiatry of Ireland and the Irish College of General Practitioners (ICGP) has come up with a set of succinct guidelines on the management of depression in primary care.
I attended a recent continuing medical education workshop in which Dr Sandra Tighe, the tutor for the Avoca faculty of the ICGP, and Prof Jim Lucey, medical director of St Patrick’s Hospital, Dublin, updated us on the latest framework.
For mild depression, where the person is experiencing persistent low mood throughout the day with a sense of not enjoying their usual interests, there are a number of management options: doctor and patient could decide on “watchful waiting”, with a firm arrangement to reassess the situation in a week or 10 days; physical exercise may be prescribed (there are now formal exercise programmes available throughout the country); the patient may wish to try a computerised form of CBT available on the web; or the doctor may offer a brief psychological intervention if they are trained to do this.
Significantly, the guidelines do not recommend the use of antidepressants for mild depression, a situation in which some doctors may have overused medication in the past.
In the case of someone with moderate to severe depression, the ideal treatment involves a combination of antidepressant medication, psychological interventions and social support. The moderately depressed person will have a greater number of symptoms which are felt more deeply than in someone with a mild version of the illness. They will have felt unwell for two weeks or more. And they are more likely to experience somatic symptoms such as fatigue and a loss of appetite or sudden overeating as well as psychological symptoms.
Once antidepressants have been started in someone with a first episode of depression, it is recommended the patient keeps taking them for six months after the depression has resolved. If a person has had two or more episodes of depression in the past, the guidelines suggest they stay on drugs for two years after remission. The same advice holds for someone who experiences their first bout of depression after the age of 50.
What about those people with moderate to severe depression who don’t respond to medication? It is estimated this may occur in about a third of cases; if there is no response after four weeks of treatment, then starting an alternative antidepressant is a reasonable option. And the guidelines are specific about the need for close follow-up of two groups of patients: those under 30 and anyone considered to be at an increased risk of suicide.
In our discussion afterwards, one sobering statistic emerged: a man who experiences one episode of (untreated) moderate depression in his 50s has a one-third less chance of being alive when he reaches 65 than a man who does not experience the illness. It’s a brutal reminder of depression’s role as a risk factor for heart disease and premature death.
The link between moderate and severe depression and premature death is probably the most powerful argument against critics of the modern management of the condition by doctors. Not treating depression vigorously is, in my view, as culpable as knowingly not treating elevated cholesterol or high blood pressure in a person at risk of heart disease.