Wednesday, June 25, 2003

Many seek help for depression but often don't get it, study says

A study published in the most recent issue of the Journal of the American Medical Association found that while more Americans are seeking help for their depression, the treatment they find is often inadequate.

According to Dr. Ronald Kessler, a lead researcher for the study that was sponsored by the National Institutes of Health, a major reason why people don't receive enough care for depression is that they usually go to family doctors. These doctors often are not well trained to diagnose and treat depression. They often prescribe antidepressant medications, but give too low a dose.

Dr. Frederic Flach, a psychiatrist and the author of "The Secret Strength of Depression," says that antidepressants can be very helpful in treating depression, as long as they are used correctly.

It is true, he says, that the number of people seeking medical help for depression has increased significantly since the introduction of the newer antidepressants, in particular the serotonin reuptake inhibitors that increase the levels of the biogenic amine serotonin at the nerve junctions (where one nerve speaks to another) in the central nervous system (the brain). Examples of such drugs include paroxetine (Paxil), sertraline (Zoloft), and fluoxetine (Prozac).

Some of the other antidepressants, such as venlafaxine (Effexor), increase the amount of norepinephrine while still others, such as bupropion (Wellbutrin), raise the levels of dopamine. In contrast to earlier antidepressants, like imipramine (Tofranil) or amytryptiline (Elavil), the side-effect profile of these newer drugs is remarkably benign.

As a result, most of the antidepressants are administered by primary care or family physicians. That's fine, Dr. Flach feels, as long as the doctor is adequately trained to recognize depression and use the drugs effectively, and as long as he knows when not to use them, or when to combine them with psychotherapy (talk therapy) or interpersonal adjustment therapy (husbands and wives together). The doctor must also know when and where to refer patients for these other kinds of treatment and remain in ongoing contact with the therapist(s) throughout.

Rather than dishing out antidepressants irresponsibly, the chances are that the primary care physician is still using them too sparingly, or using them in isolation and not within the framework of total treatment. "For many patients, that may be enough," Dr. Flach said. "Given the right medications, they can make the necessary personality and interpersonal changes on their own initiative, 'with a little help from their friends.' Just as often, however, they can't."

"Moreover," he added, "managed care seriously limits the amount of time primary care physicians can spend with patients, making it harder for them to arrive at an accurate diagnosis, much less to provide the supportive understanding and empathy patients require."

The question of whether the antidepressants really work is a more troublesome one. In controlled studies involving large groups of depressed patients, some receive the antidepressants while others receive a placebo (an inert substance meant to look and taste like the real stuff). When the study is over, the two groups are compared. If a statistically greater number of patients receiving the drug show clinical improvement as compared with those who received the placebo, one may conclude that the antidepressant works to relieve depression. For practical purposes, it is enough to satisfy the Food and Drug Administration and permit the pharmaceutical firms to market it and doctors to use it.

"But in any such study there are a number of patients who improve on placebo," Dr. Flach said. "There are also a number who do not improve on the drug. We don't know why this is so, but we can speculate."

Even if all patients look alike and register alike on psychological tests for depression, it does not mean they are actually alike. Their basic conditions may be quite different biologically. Or their personality characteristics, relationships, and environmental considerations may be quite dissimilar as well.

In practice, most knowledgeable psychiatrists can support the efficacy of the antidepressants. They have given them often, and often they have seen patients who would be unlikely to respond otherwise recover within the anticipated time frame of 3 to 6 weeks.

"The real issue here is that these drugs are misnamed. They probably shouldn't be called antidepressants at all. I call them resilience-enhancing agents," Dr. Flach said. He envisions them restoring a biological equilibrium to a disturbed nervous system, perhaps by increasing the amount of serotonin at nerve junctions or more likely this effect is only the tip of a much more complex mountain of biochemical mechanisms. This idea has meaning far beyond the world of research, for it shapes how doctors and patients regard the use of these medications.

"If I tell depressed patients that the drug I am about to prescribe is a resilience-enhancing one, meant to restore normal functioningnot unlike giving thyroid hormone to someone whose thyroid gland is under-performing or insulin to a diabetictheir acceptance level is enhanced; they are greatly comforted by the idea that the antidepressant is not about to give them a false high, that it is not habit forming or addicting, that they will likely not have to be on it forever, and that, as they improve, their improvement will not merely be the result of the drug, but very much a matter of their own efforts as well," he concluded.