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Without wishing to devalue the importance of clinical assessment of patients, I am excited that we are beginning to define depression better at a biological level.
There is a lot of active research into genetic markers of depression, neuroimaging and preclinical work on depression that could soon translate in ways that will help clinical practice.
Many other medical specialties are ahead in this regard and some already use biological markers in diagnosis and evaluation. Take cardiovascular medicine for example – where it is routine to use a range of biomarkers within an integrated composite that is used to prognosticate and guide management. I work in a large neurology department and in the past decade we’ve seen other psychiatric diseases move in this direction, with for example diagnosis and assessment Alzheimer’s disease now involving blood markers, spinal fluid assessment and MRI as well as clinical evaluation of the patient.
We would be wrong to try to look for any single biomarker in depression but we do need biomarkers indicative of mood regulation and cognitive regulation. The likelihood is that there needs to be a set of biomarkers.
I view the combination of psychiatric and psychotherapeutic approaches to the care of patients with depression from a number of perspectives. Firstly, on a practical level – a real and common issue is: is psychotherapy available? Not just access to a service but also access to competent therapists and appropriate psychotherapy. By that I mean that some patients may need therapy to support interpersonal relationships, others require psychoanalysis and so on.
The second issue is – and I think we don’t know the answer to this – when should we combine psychotherapy and pharmacotherapy? It might be presumed that two approaches are better than one, but this isn’t always the case. In fact some data suggest the reverse. There is also a question of when to apply psychotherapy – should remission be induced using drug treatment and then psychotherapy used to consolidate drug treatment?
Then thirdly, how do we define psychotherapy? There are as I mentioned a number of different types of therapy and in depression – we also call upon cognitive behavioural therapy (CBT), which is not really a form of psychotherapy.
The way we define remission in depression is based on using mood scoring systems, yet the real endpoint we are seeking is a state where there are no residual symptoms and a full recovery of patient function. It takes time for patients to fully recover from their depression. Patients experience a change in their ‘relationship with themselves’, that can affect confidence and erode their social reputation. We need to assess and address these factors.
It takes time for patients to fully recover from their depression.
There is research and study – not all of it new – that shows we are capable to addressing the complexities of brain diseases. Studies looking at deep brain stimulation as a therapeutic manoeuvre suggest that if we can identify the physiopathological abnormality in a neurological disease, we may be able to treat or target that abnormality.
In depression, we give antidepressant drugs that target the serotinergic system, and while that is not an incorrect approach, there may be abnormalities at a biological level that need to be targeted more directly. Indeed we know that depression is not a disease where “one size fits all”.
Things are changing and we will move and progress to an era when we can offer truly individualized medicine to patients with depression, but I hope we don’t loose the features that make us good psychiatrists and practitioners, able and willing to truly interact and engage with our patients as people.
Our correspondent spoke to Professor Philippe Fossati of the Hôpital de La Salpêtrière in Paris to hear some of his views on challenges and issues around contemporary management of patients with de
The depth of depression in some of our patients is not well captured by MADRS and HAM-D. Even when the scores are high. Though we do use them, they do not necessarily capture the full depth of depression of emotion in some patients. Lots of emotional information is lost. Perhaps this is too much to ask of a questionnaire! But you can get the information by talking and, above all, listening. It’s about empathy.
And that’s what I try and do. Of course, it’s time consuming. But if I am on call and not too busy, I go to the acute unit and sit and talk to patients. We talk about anything – what they’re watching on TV, politics, religion, football. What they think about the world. What they think about their therapies. Anything that moves them.
I use both drugs and psychotherapy – Acceptance and Commitment Therapy (ACT). If you are anxious or depressed, most of the time you hide. You avoid things. And if you do that, slowly but inevitably, your life becomes empty. And if your life is empty it is impossible to recover from depression.
The therapy is about accepting the fact that you may not be able to control your thoughts and the feelings that come with them. But you can control your actions and the values and direction of your life. The commitment is to act according to your values to rebuild your life. To approach once again your family, your health.
I use this therapy in combination with antidepressant drugs. Ours is a private hospital, so patients are paying. And part of our job is to make sure they get the most effective combination of treatment that is possible.
Dr Jose Antonio Aguado of the Hospital Benito Menni, Valladolid, Spain, talks about his approach to the management of depression and the importance of combined treatment.
A: Cognitive deficits are really important to patients and this is often what they come in to the office to report – particularly when they have seen an improvement in their mood. Many of my patients think that these residual effects are actually related to their antidepressant treatment.
These can be residual symptoms that interfere with functional activity. In daily life, this may be seen at work and at home, where memory is affected, with patients not remembering what tasks they have to do.
A: My strategies for dealing with cognitive symptoms in patients with depression include trying to use an antidepressant with wider aspects – or I may use addition drug therapies or cognitive remedial strategies. Not all patients are the same and it needs an individual approach.
An interview with Dr Narcis Cardoner, Psychiatrist, Bellvitge Hospital, Barcelona, ES about cognitive symptoms of depression