Depression is more than the “blues” or feeling down: it is a serious and surprisingly common illness that will affect between five and 18 percent of us at some point in our lives. And for those of us who suffer one major depressive episode, 50 to 60 percent of us will have a second and 70 percent of those people will have a third. How depressing! The good news: depression is now recognized as an illness, not the stigma that it once was, and new research is shedding new light on ways to treat it. Family physicians, psychologists and psychiatrists have all been trained to diagnose and treat depression. The U.S. Preventive Services Task Force (USPSTF) recommends screening adults for depression in primary care offices by asking some variation of these two questions: over the past two weeks, have you felt down, depressed or hopeless? Have you felt little interest or pleasure in doing things? If you answer yes to either question, your doctor should follow up with the SIGECAPSS questions on Page 64. But even then, depression is often missed, up to 60 percent of the time on a first visit. Patients (and doctors) tend to focus on the symptoms of fatigue, disturbed sleep and aches and pains, not feelings. The good news is that doctors do diagnose depression at follow-up visits in at least half of the patients we initially missed. Treatment options include medication, counseling or both, but until recently we didn’t have great evidence about treatment strategies. Most pharmaceutical trials aren’t applicable to the real world: they typically study one medication at a time; patients are recruited and have few or no psychiatric co-morbidities such as anxiety or substance-abuse problems; only the most severely depressed patients are entered in the trials and once they’re enrolled, patients usually have no say in their treatment choice. The National Institute of Mental Health recently completed the STAR*D trial, short for Sequenced Treatment Alternatives to Relieve Depression, to give us more real-world answers to the question of how to treat depressed patients. All patients who complained of depression, even those with mild and moderate cases, were enrolled and at several points in the trial they had choices about their treatment. The study’s conclusions are many: • Antidepressants don’t work as well in the real world as they do in ideal study conditions • Adding a second anti-depressant or switching to a different one does help though adding or switching medications a second or third time doesn’t help as much • Adding counseling or switching from medication to counseling was as effective as changing medications • At the end of the study, two-thirds of patients were essentially symptom-free. What does this mean for you? Pay attention to your feelings. If you think you might be depressed, see your doctor. If you are prescribed medication, stick with it for 14 weeks, but even if you can’t see a change, don’t give up. Tell your doctor and ask to switch medications, add medication or get counseling. Don’t settle for improvement, seek remission. Exercise helps you feel better, drinking alcohol makes depression worse. Cognitive behavioral therapy, the type of counseling studied in the STAR*D trial, is a good substitute for or adjunct to medications. Dr. Lenny Salzberg sees patients and teaches at the Southern Regional AHEC Family Medicine Center.
