Depression Can Be Managed Effectively

Summarized by Robert W. Griffith, MD
February 25, 2005

Introduction

People with depression don't receive the sympathy they deserve. It's one of the greatest causes of disability, yet there are effective treatment regimens that can reduce the burden it causes. Unfortunately, the best treatments aren't always available to all depressed patients. An Australian study, reported in the Archives of General Psychiatry, has analyzed the likely effectiveness of different strategies for long-term management in people with major depression. Here's a summary of the findings.

What was done

This study differs from many we've described in these pages; it used published information on the effectiveness of different regimes to estimate the results to be expected in Australian adults with major depression. It then compared the projected results with those based on the actual treatment currently used.

Comparison was made between the amount of depression experienced with current methods, theoretical 'expanded' use (i.e. full use of antidepressant drugs and/or cognitive behavioral therapy (CBT)¹), and theoretical absence of any treatment.

Health gains were expressed as prevention of relapse, reduced severity of episode, and prevention of suicide. The treatment options evaluated were antidepressants both during and for 6 months after an attack, CBT for 1 year, maintenance antidepressants, and maintenance CBT for 5 years.

The result of calculations using the model

Evaluating the year following an acute episode, it was found that current treatment measures would prevent 10% of the disability burden to be expected with no treatment. Treatment during the episode with an additional 6 months of CBT would raise the prevention level to 28%, while 6-month maintenance antidepressant therapy would give a prevention level of 24%.

When a 5-year period was considered, limiting treatment to the episodes would prevent 10% of the disability burden, whereas full maintenance using CBT would raise the prevention level to 52%, and continuous antidepressants to 50%.

The next analysis looked at the sort of improvement offered by different therapeutic approaches. The proportion of health gain over a 5-year period is displayed in the table:

It can be seen that prevention of suicide comprised about 30% of the 'health gain' with each of the four treatment options, compared with no treatment. Preventing relapse was more relevant for long-term maintenance therapy (drugs or CBT), whereas reduction in severity of episodes was more influenced by both the shorter-term treatments.

What these calculations mean

First, it must be remembered that this is an Australian study, and that the results don't necessarily apply to what would be found for other countries, although it's likely that they would. Second, they are theoretical results; an ideal study would compare actual results with the four different approaches in real life, together with a 'no treatment' group. Such a study - at least one including a no-treatment group - cannot be done, as it would be completely unethical.

In spite of these limitations, the results obtained show quite clearly that better overall results are likely to be obtained with prolonged maintenance treatment. While shorter-tem treatment appears to improve the severity of episodes more, the overall burden of disability that depression produces is clearly reduced with either drugs or CBT given for at least 5 years.

This particular study didn't attempt to analyze the likely effectiveness of combining drug treatment with CBT, but other studies have done this, at least in the short term, and found that there is, indeed, a synergy (see first link, below).

The important aspect of this study is the revelation that depression is a chronic disorder that requires longer-term treatment than has been thought necessary, so far. For anyone who has, or has had, a major episode of depression, it's important for them to keep in close touch with their physician, to ensure that treatment can be re-instituted as soon as seems necessary.

Source

• The burden of major depression avoidable by long-term treatment strategies. T. Vos, MM. Haby, JJ. Barendregt,  et al., Arch Gen Psychiatry, 2004, vol. 61, pp. 1097--1103

Footnotes
1. Cognitive behavior therapy (CBT) combines two very effective kinds of psychotherapy - cognitive therapy and behavior therapy. Cognitive therapy helps the patient recognize how some thinking patterns can cause symptoms by giving a distorted picture of what's actually happening, producing anxiety, depression, or anger. The intent is to alter the patient's way of thinking. Behavior therapy is designed to break down the connections that have been built up between troublesome situations and habitual reactions to them. It also teaches how to calm the mind and body, so one can think more clearly and make better decisions.

Related Links
Treating Depression at Home
'Beating the Senior Blues'
Self-Help for Depression?
Understanding and Helping the Suicidal Person