We Need Better Depression Treatment, Not Simply More

According to a study published today in the Archives of General Psychiatry only half of all people with depression received treatment. And among those who did receive treatment, only 21% were getting care that is consistent with American Psychiatric Association guidelines.

Naturally, the media ran with the depression-is-undertreated theme. See here here and here for examples. In a sense, that's a feel-good story, a reassuring spin. Figuring out depression is just a technical matter of routing more sufferers into an effective treatment. We can all go home happy, or at least no longer depressed.

One could quarrel about the actual trends. In point of fact, the public increasingly seeks treatment for depression. For example, just between 1977 and 1987, the rate of outpatient treatment for depression tripled from 0.73 per 100 persons to 2.33 per 100 persons. (Olfson et al., 2002). Moreover, the public has also become more accepting of treatment seeking (Motjabi, 2007).

But the just-get-people-into-treatment message misses something more fundamental. Our supposedly effective treatments for depression are not all that effective.

Make no mistake, our pharmacological and psychologically-based treatments are better than nothing. But it's time to be candid: these approaches have taken us to a state of diminishing returns.

Existing treatments leave the majority of patients (even patients who respond) with residual symptoms. For discussion purposes, let's consider antidepressants, in many ways the dominant treatment of our time. In one of the largest treatment studies ever of serious clinical depression, the Star*D treatment trial, which was based on 2,876 patients who were tested across the United States at 41 different sites, 72 percent of the patients still had significant residual symptoms even after 14 weeks of antidepressant treatment. These residual symptoms are more than just a nuisance: they include a nagging low mood, concentration difficulties, continuing insomnia, and feeling that the self is worthless. Even those patients who respond well to a treatment initially are not in the clear. Sadly, their depression will, more likely than not, recur.

As if to hammer home the point, today another major study came out in the Journal of the American Medical Association, reported in the New York Times, with even more chilling results. In a reanalysis of six large clinical trials, Fournier and colleagues found that for people who have mild to moderate depression, common antidepressants worked little better than inert placebo pills. The benefits of antidepressants, when they worked, were confined to people who had severe depression. This is a very important analysis because the majority of depressed people have the mild to moderate variety and not the severe variety.

Undertreatment of depression is not the real story; the real story is the recalcitrance of depression, even to state-of-the-art treatments. That's the hard truth we should be telling the public.

We need better treatments, not simply more of the same. If we are to start to contain depression, the public needs to demand them and to agree to fund the research that will bring them into being. Once we have more effective treatments, then, yes, we can put all of our energy into making sure that sufferers are routed into them. But for now, the very first step should be on research, research that will help us understand why depression is such a tough nut to crack.

References

Fournier et al. (2010). Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-analysis JAMA, 303: 47-53.

Hector et al. (2010). Depression Care in the United States: Too Little for Too Few. Archives of General Psychiatry, 67, 37-

Olfson, M., Marcus, S.C., Druss, B., Elinson, L., Tanielian, T., & Pincus, H.A. (2002). National trends in the outpatient treatment of depression. JAMA. 287, 203-209.

Motjabi, R. (2007). Americans' attitudes towards mental health treatment seeking: 1990-2003. Psychiatric Services, 58, 642-651.