Major depression – an interview with Dr Miguel Rangel, Mexico

What do you think are the most significant challenges that face psychiatrists treating patients with major depression?

The most important challenge is reaching recovery – achieving remission is often possible – but recovery is the main challenge. Remission is achieving a point where there are only slight symptoms and we usually use scales to measure that state. But recovery is even more important for the patient – because recovery means recovery of function in life.

What proportion of your patients experience remission?

Most antidepressants lead to remission in around 60% of patients, but patient recovery is often achieved in only around 20-30%. Probably about 30% of patients who seem to have remitted will come back with a relapse, then around 20% will have resistant depression that may need a combination of drugs.

Many of the tools we use to measure remission and recovery – like the Montgomery-Asberg (MADRS) and the Hamilton (HAM-D) rating scales are good but they are very old – and we need scales that are more realistic and which take a more patient-focused view of depression. The tools we have are not very specific and they don’t really take the point of view of the patient, which for me is very important.

In recent decades – what have been the most significant advances in the treatment and management of depression?

The antidepressants we have are important tools but they are not sufficient alone – and that’s why we need a multifactorial approach – multimodal treatments – drugs, psychotherapy, lifestyle changes.

Now we have a most multifactorial approach to patient care   and that’s an advance. The newer antidepressants have the same efficacy as older drugs but tend to have fewer side effects.

The antidepressants we have are important tools but they are not sufficient alone – and that’s why we need a multifactorial approach – multimodal treatments – drugs, psychotherapy, lifestyle changes.

Do you look for cognitive symptoms in depressed patients?

Yes and that is something that is really important. It helps the recovery – it helps patients get back to work and to real life. With the first antidepressants – we thought that the most important aspects of treatment were to help relieve patients of suicidal and depressive thoughts – now we realize that cognitive issues are important too.

I look at cognitive function right from the beginning. It’s important in Mexico and in some other similar countries – where patients who get a diagnosis of depression may not be entitled to a sick-note that allows them to be off work. We want no cognitive symptoms and we want treatments without sedative effects – so that patients can get back to work and to function. We also want treatments to work within 2 to 3 weeks.