One of the most challenging parts of the treatment of patients with mood disorders is assessment. Often we look too broadly and we are not specific enough. This is especially the case in primary care but even at the tertiary care level, we are often too general. The problem is that we tend to take a symptom-orientated approach, rather than looking at the patient’s day-to-day function.
That’s not to say that symptoms aren’t important. It is necessary to improve mood but really we need to be looking to improve a patient’s function – that means improving function in the workforce, or for students, at school or university, improving learning function, as well as improving social function.
It all starts with our initial approach. As well as determining symptom severity using standard tools and structured interviews, we like to assess domains of function that span cognitive, social and workplace function.
One of the hot topics in depression at the moment is identifying biomarkers. At ECNP this year there has been a lot of discussion on this. Ideally we would be able to sub-stratify patients right from the start. Currently we tend to take a backward looking view when we should be more forward thinking in terms of the patient trajectory.
There a huge initiative in Europe looking at neuroimaging markers and biomarkers. If in addition to the broad clinical assessment of the patient with depression, we had blood biomarkers and neuroimaging markers, we could combine these right at the beginning in a way that for example might help predict the likelihood of the patient experiencing future episodes of depression as well as helping inform our management decisions.
None of this is a reality in practice as yet. But we are now seeing a shift away from research that used to be very cross-sectional in its view, towards more prospective research. This is happening internationally and nationally, and across research networks and consortia. I expect in the next 5-6 years this big effort across a number of fields of research will pay off and we will be better able to stratify our patients.
In terms of the management of patients with depression, personally I am a fan of combining psychiatric and psychotherapeutic approaches to care. And there is objective evidence that the combination of drugs and psychotherapy is better overall than drug treatment alone.
More controversial is the order in which you apply such treatments. What order or sequence – whether to combine from the outset – or whether to add one treatment to another. It may be better to start with drug treatment in order to get symptoms under control and to help the patient reach a point where they become more amenable to psychotherapy.
Of course, this leads on to how we define remission in depression. The standard tools and scales we use are a bit outdated. Our definitions of remission don’t take into consideration patient function and so are therefore not helpful.
In fact I don’t like the word “remission”. We need to be looking at defining our treatment success with function in mind.
There is a correlation between improvements in mood and improvements in cognition in depression, but about a third of patients experience an alleviation of mood without any change in cognitive function.
We need to assess the deficits in the first place and to look, with the patient, at what they’d like to achieve. Then we can develop a treatment strategy that combines pharmacological and non-pharmacological treatments. This means using antidepressant therapies. I would never use agents that are specifically indicated for treating cognitive deficits, or agents indicated in ADHD for example in these patients. I’d be looking to use antidepressants based on evidence of effects on both cognition and mood. Then in my practice I’d want to define a programme of non-pharmacological interventions, designed to improve cognitive function and encompassing physical activity and life style changes.