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Monday, November 5, 2007

1 Myth about depression mostly not covered

The comment of a reader (Aqua) on a recent post emphasized that another myth about depression is it's outcome. To the contrary that most doctors would like, not every patient gets well. Recently we treated an elderly woman with severe depression. Intensive medication treatments such as a tricyclic antidepressant with lithium addition did not help her. She couldn't tolerate an irreversible monoamine oxidase inhibitor. We thought that ECT would do the trick as in most severely depressed. But she didn't get well after about 20 bilateral ECT treatments.

For a number of chronic medical conditions including diabetes, arthritis, chronic pain and asthma, disease management programs exists. The goal of these treatments is to help the patient focus on their well-being in spite of their illness.

These programs focus on:
1. medical management of their condition
2. maintaining, changing or creating meaningful behaviors or roles
3. dealing with the emotional sequelae of their chronic condition
4. promoting an active and central role in managing their illness.

The focus is more on functioning and quality of life than on symptoms.

Trying to find research on persistent depressive symptoms and their management delivered only a few articles. Most programs still have as their ultimate goal the reduction or elimination of depression.

A recent systematic review and meta-analysis of randomized controlled trials of disease management programs for depression included 10 trials. The disease management programs did have a significant effect on depression severity compared to primary care but the focus was mainly on pharmacotherapy.

Two other forms not focusing on pharmacotherapy are:
1. Well-being therapy: enhanced sense of mastery, engendering the positive.
Focus on environmental mastery, personal growth, purpose in life, autonomy, self-acceptance, and positive relations with others.
2. A more preventive approach is Mindfulness-Based Cognitive Therapy. It teaches patients how to decenter and disengage from automatic cognitive processing patterns that are linked to relapse. Meditation is used in this program. The link goes to a site about this treatment.

All considered some disappointing results still. Psychiatry might consider looking at the treatment programs of chronic somatic illness.
My posts about relaxation techniques aren't that much off topic after all.

Articles discussed:
J Clin Psychiatry. 2006 Sep;67(9):1412-21.
Realistic expectations and a disease management model for depressed patients with
persistent symptoms.
Keitner GI, Ryan CE, Solomon DA.

Med Care. 2004 Dec;42(12):1211-21.
Disease management programs for depression: a systematic review and meta-analysis
of randomized controlled trials.
Neumeyer-Gromen A, Lampert T, Stark K, Kallischnigg G.

Blogging on Peer-Reviewed Research


Aqua said...

Thank you so much for writing about this topic. I feel a little less alone after reading this. Also, I really am trying to put into practise some of the things you talk about in this article.

My pdoc provides supportive therapy and his encouragement helped me become more involved in meaningful activities developing my artistic self. I have also begun teaching art classes in a supportive art clubhouse environment for people with severe and persistent mental illnesses.

I find both the art and the opportunity to teach art have provided me with a sense of purpose like I have never felt. They have also increased my self esteem.

I am still trying to find medication/s to help me, but the art and classes, and the unflagging support my pdoc provides are what is helping me keep trying in spite of this unrelenting illness.


Dr. Shock said...

You have my admiration, regards Dr Shock

Dr. Shock said...

You have my admiration, regards Dr Shock