WASHINGTON-The treatment of depressive disorders believed to affect 5-10.3 per cent of the general American population has changed markedly during the past decade as pharmacological treatments multiply and the stigma of depression dissipates.

As researchers continue to make advances in the treatment of depressive disorders, however, unipolar major depression represents the fourth leading cause of disability in the world and is expected to become the second leading cause by 2020, according to a research article published by the Journal of the American Medical Association (JAMA) in January. The adverse health effects of depressive disorders as measured by the impairment of normal human functioning matches that of heart disease and exceeds those of diabetes, arthritis, and peptic ulcer disease, JAMA reported.

Although it is generally held that most people suffering from depression do not receive treatment for their ailments, researchers have discovered that depression patients today are far more likely to receive psychotropic medications and slightly less likely to receive psychotherapy than they were in 1987. According to JAMA, the proportion of patients treated for depression that received medication rose from 44.6 per cent to 79.4 per cent between 1987 and 1997. The research indicates that depression patients were 4.5 times more likely in 1997 to receive psychotropic medication than in 1987.

Further, 87.3 per cent of depression patients who received outpatient care by 1997 were treated by physicians compared to 68.9 per cent of outpatients in 1987. The proportion of outpatients who received care from psychologists likewise declined to 19.1 per cent from 29.8 per cent during that period.

Though some experts lament the decline in outpatients receiving psychotherapy, asserting that a combination of drugs and therapy works best, others see a silver lining in the trend.

"It's a good thing that more people are getting any kind of treatment for depression," said Dr. Richard R. Owen, director of the Department of Veterans Affairs (VA) Health Services Research and Development Center for Mental Healthcare and Outcomes Research in Little Rock, Ark. Yet, Dr. Owen added that VA researchers have "some concern" about the trend toward medication and away from psychotherapy because research indicates that certain types of psychotherapy-such as behavioral and interpersonal therapy-are effective but are not as readily available as medication to primary care patients. "My impression of the literature is that in many cases no matter what the severity [of the depression], combined treatment is the most effective," he said.

Dr. Owen said that while psychotherapy and modern depression medications may be equally effective when used alone against the disorder, depression patients should have greater access to psychotherapy to help prevent relapse. Currently, patients in many managed care systems are only referred to psychotherapy for severe clinical depression.

Yet, patient preferences for the delivery of mental health care vary by population, according to JoAnne Kirchner, PhD, a psychiatrist who received a grant from the VA Health Services Research & Development program. "Many elderly [patients] prefer to have their care provided within a primary care setting," she advised, because they have greater access to primary care and believe the stigma is lessened when mental health care is more closely associated with primary care. Also, the elderly sometimes have difficulty navigating through a new system of health care, she said.

DoD's Approach To Depression Treatment
Depression treatment within the Department of Defense's (DoD) health care system is multi-faceted and, like other systems, incorporates an array of health care providers, including physicians, psychologists, social workers, mental health care workers, psychiatric nurses, occupational therapists and chaplains, according to Lt. Col. Elspeth Cameron Ritchie, MC, USA, program director for mental health and women's issues for DoD health affairs.

"We also in the vast majority of cases do combine treatment with SSRIs [selective serotonin reuptake inhibitors] [and] psychotherapy," Dr. Ritchie told U.S. MEDICINE in February. "Certainly the ideal would be to treat [depression] with both medication and psychotherapy" to prevent the risk of relapse, she said. Yet, the risk of relapse exists with any disease, she added. Thus, varying levels of treatment are appropriate for depression given that the disorder strikes individuals in varying degrees, from the most severe chronic depression to milder forms that are acute reactions to specific situations.

Dr. Ritchie noted the role of the military chaplain, who provided counseling to depressed or otherwise troubled soldiers long before the development of modern psychiatry and medication. Like the elderly, who may feel more comfortable seeking mental health care from primary care physicians, soldiers are sometimes more likely to seek dialogue with chaplains, wary of the stigma associated with mental health problems.

DoD has striven to reduce the stigma of mental health care, and therefore ensure that more depressed individuals receive treatment, by taking a couple of different tacks, according to Dr. Ritchie. In addition to efforts to educate personnel about suicide prevention, the military has taken mental health care out of the office and into the field in the form of combat stress control units and other efforts. Rather than sending an individual to an office somewhere, DoD often sends someone who is in the same unit, or is known to the unit, to talk to someone who may have mental heath problems.

Dr. Ritchie emphasized that the development of progressively safer pharmacological treatments has meant that many mental health problems, such as depression, are now treatable and do not compromise the integrity of the armed forces. "We're trying to treat [depression] in a way that doesn't endanger somebody's career and we now have a lot of safe, very effective treatments we can use that allow somebody to stay on active duty," she said. Thus, more individuals are likely to seek or accept treatment for mental health problems.

Dr. Ritchie acknowledged that, as in the civilian world, depression is a health problem for the military. Although DoD has no concrete statistics for the rate of depression among personnel, the military tracks suicide rates, which may correspond to the rate of depression. Dr. Ritchie noted that while the military strives to reduce its suicide rate of 12-14 per 100,000 per year, the rate has traditionally been lower than that of the civilian population.

According to the National Center for Health Statistics in Hyattsville, Md., the suicide rate for the general American population in 1999 was 10.7 per 100,000, down from 12.14 per 100,000 in 1990. The same figures show 17.6 suicides per 100,000 American males compared to 4.1 suicides per 100,000 American females in 1999. Though females attempt more suicides than males, the male suicide rate is significantly higher because men are more apt to use firearms, Dr. Richie said.

Screening For Depression And Making Diagnoses
Like fishermen casting nets, mental health professionals design depression screens to catch individuals with varying degrees of symptomatology. "When we screen, that's to identify a segment of the population that's at higher risk for the disorder," said Dr. Kirchner, adding that the parameters of the screens, such as sensitivity and specificity, can be modulated depending upon criteria for diagnoses.

Initial screenings may catch as much as 30 per cent of a given population, Dr. Kirchner said, which allows health care workers to then eliminate patients whose symptoms may be caused by medical problems, substance abuse, grief and the dissolution of romantic partnerships. Common medical problems with symptoms that can be confused with those of depression include cancer, low thyroid levels, alcohol abuse, and anemia. Often, mental health care professionals cast such wide nets to ensure that truly depressed individuals do not slip away. "We also know that we're not very good at picking up depression, and even when we [in the mental health care field] pick it up, many times we don't diagnose it because of some of the issues of stigma and other issues," Dr. Kirchner said.

Conversely, some physicians may actually detect and treat depression without making a depression diagnosis, Dr. Kirchner said. In reference to a study of rural populations, "sometimes docs know there is depression and do not diagnose because of stigma but do prescribe lower dose [medications]," she said. Such physicians may choose to treat mild depression without making a diagnosis because of stigma or the lack of reimbursement for depression treatment in some healthcare systems.

"Now within VA, frequently we see that there may be individuals who are prescribed antidepressant therapy [but] may not receive a real clinical diagnosis," she said, adding that such practices are not well-known but are being studied. Dr. Kirchner acknowledged that many low-dose antidepressants are used to treat disorders other than depression, such as insomnia, nicotine addiction and other neurological problems. "But that doesn't account for the complete picture of the lack of associated diagnoses with the prescribing of antidepressants," she said.

Building Consensus
Regarding the general American population, former surgeon general Dr. David S. Satcher last year released a report on depression that listed stigma as a serious barrier to treating it. "For our [n]ation to reduce the burden of mental illness, to improve access to care, and to achieve urgently needed knowledge about the brain, mind, and behavior, stigma must no longer be tolerated," the report stated.

In general, the stigma of depression has been reduced, according to Dr. Owen, who noted that VA has screened all primary care patients for depression since 1997. Current stigmatic beliefs about depression among the elderly today, for example, may be a cohort or "generational" effect, Dr. Owen said. "Maybe people who are [currently] middle-aged may age and not feel that way, not have the stigma," he said.

Attitudes today about depression vary as much as the degree to which the disorder affects individuals, according to Dr. Kirchner. "When we talk about depression sometimes we trivialize it; we kind of do both ends of the spectrum," she said. On one hand, Americans describe any temporary downward fluctuation in mood as "depression," but nevertheless stigmatize the more serious degrees of depression, Dr. Kirchner said. Also, many people believe that depression among the elderly is not only acceptable, but to be expected. "That doesn't account for the fact that people can experience tremendous hardships in their life and not have a depressive disorder," said Dr. Kirchner. Yet, "we do feel that there's variation based on age," she added.

Dr. Kirchner said such questions could only be answered with more research.

http://www.usmedicine.com/article.cfm?articleID=400&issueID=38

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