A NOVEL APPROACH TO MANAGING DEPRESSION
Simultaneously occurring scientific advances and social trends are contributing to a dramatic rise in the incidence and prevalence of depression. An increase in human longevity that extends to individuals with previously "life shortening" now chronic illnesses; and, an American culture that becomes more stressful, global, isolated and fast paced by the minute have contributed to depression's current status as a major public health problem. Despite the fact that depression is a leading cause of disability worldwide, it is often ignored or addressed only after it has evolved into a severe, life threatening condition. Once recognized, treatment may be further delayed because of stigma, misinformation, ignorance and shame. When treatment is initiated, approaches are inconsistent and dependent on providers from diverse professional and paraprofessional disciplines with distinct sometimes divergent philosophical and theoretical perspectives regarding how depression is defined, its causes, definition (s),and best treatment practices. This creates confusion regarding the paradigm or world view of depression that should provides the basis for research and treatment initiatives. Thus practices are vulnerable to undue influence by pharmaceutical and managed care companies whose motivations center on profit rather than patient care. This process has fostered divergent and competing treatment guidelines, practice standards and research and treatment initiatives that focus almost exclusively on antidepressant medications. This narrative will address depression as a major public health issue, that should be managed using a comprehensive, multimodal approach that extends beyond the current, wholly inadequate use of antidepressant medication alone.
Depression exists on a continuum ranging from transient, non clinical sadness to a variety of serious, life threatening disorders requiring aggressive psychiatric intervention. Depression at all points on the continuum can cause significant impairment in an individual's ability to function, and is a leading cause of disability worldwide yet resources remain limited. Limited access to comprehensive treatment has been linked to numerous negative effects on individuals, their families, the social and economic welfare of our nation and beyond. Despite the rising incidence and prevalence of depression it continues to receive inadequate resources for research, prevention, treatment,and professional and public education. Studies support the idea that the most effective treatment for depression combines antidepressant medication, cognitive behavioral therapy, education, and support and that a combined approach is more effective than unitary antidepressant treatment alone. This makes sense based on the multiple factors linked to the depression etiology. In practice however patients typically receive antidepressant treatment alone. This may relate in part to the fact that funded research has been focused on the most severe depressive subtypes that are most responsive to antidepressant medication.
Cases of severe depression have been clearly linked to genetic vulnerability associated with aberrant neurotransmitter concentrations within the central nervous system. As mentioned, most research has been skewed toward the most severe depressive subtypes with the stated goal of predicting positive response to pharmacotherapy. This is in spite of data supporting the fact that less severe forms of depression are increasing most rapidly, and are associated with negative clinical and cost outcomes comparable to those associated with more severe depression subtypes. This raises three important questions 1. Why are unitary pharmacologic interventions often the sole treatment for cases of severe depression despite research stating need for a combined approach; 2. Based on efficacy of antidepressants in severe depression, can the assumption be made that antidepressants are the most appropriate treatment across the depressive spectrum, in the absence of research evidence; and, 3. Can antidepressant treatment be used in varied age groups including children and the elderly without sufficient evidence that it is safe and effective in those populations?
Research and development of new antidepressant medication provides tremendous profit for the elite powerbrokers of corporate America. It is no coincidence that they also provide instant, albeit temporary gratification to vulnerable consumers, yet over the long term especially without simultaneous therapeutic approaches may make depression worse. Research has repeatedly shown that when antidepressants are given without concurrent psychotherapeutic approaches aimed at modifying distorted, depressive cognitions, improvement is incomplete and transient.
Consequences of our limited attention to depression as well as our narrow treatment focus are complex and far reaching. For example, the dramatic and highly publicized rise in chronic illnesses such as obesity, and type 2 diabetes, are overwhelming the U.S. healthcare system. There is little argument that untreated depression fosters the unhealthy lifestyles that increase risk for diabetes. There is less disagreement still, that depression interferes with self care, limiting activities associated with preventing the disease, diagnosing it early, and/or receiving comprehensive treatment after diagnosis. As depression increases as a public health concern, funding for depression research and treatment have diminished. Further, insurance companies deny claims for depression treatment and usually reimburse a lower rate than for they do for medical illnesses. This has decreased the number of students and trainees with interest in psychiatric specialization. Many existing psychiatric specialists have grown tired of fighting with insurance providers who refuse to reimburse for treatment. So, in addition to the complex barriers to depression treatment already discussed, the number of psychiatric specialists especially those equipped to treat the most vulnerable populations (children, the elderly and the severely mentally ill) is declining rapidly. Paradoxically, quality treatment for depression in the 21st century is a luxury reserved for the most socially, psychologically and financially fit among depressed patients. Finally, funding cuts have led to a diminution not only of psychiatric specialists but of specialty treatment centers in general meaning that more individuals who suffer from depression are seen in non psychiatric areas where clinicians are uninformed regarding best practices. This has resulted in significant numbers of depressed cases going undetected until symptoms are severe, life threatening or disruptive to others (such as school children who may harbor symptoms for months or years but go unrecognized until they act out behaviorally.
Education regarding causes of depression, multimodal, non chemical treatment strategies, changing demographics, assessment and treatment principles and promoting awareness and access to specialized resources must be aggressively integrated into the educational curricula of future health providers. Programs to educate the public about depression must be promoted as well. Programmatic goals should include reduction of stigma, education regarding prevention and early symptom recognition to reduce human and financial costs and promoting the range of effective depression treatments, extending beyond management with antidepressant medication. Sadly, the development of such programs is a low priority. Our all-American, collective mind set demands a magic pill and instant relief from the pain of depression, a complex, multifaceted problem, multi causal problem. As Americans, we have an uncanny ability to maintain steadfast, naive beliefs in unrealistic claims. We want a quick fix for pain that has dual biologic and environmental roots, took years to develop and requires planned, diverse and resource intensive solutions. The successful treatment of depression rests on incremental knowledge development and utilization of evidenced based, multimodal treatments delivered by skilled clinicians as well as the care, compassion and humanity that accompany treatment delivery. Sadly, the perception that humanity is a vital component of health care and a determinant of health care outcomes has eroded. These values have been replaced by profit and supremacy as the primary incentives for scientific and technological advances. This shift in incentives has precipitated a concurrent and profound shift in the medical research paradigm such that ego and profit have assumed a life of their own and are afforded more value than the vulnerable masses that need care and depend on the humanity of powerful others to provide it. Thus those in control of profit, specifically managed care and pharmaceutical companies have acquired political power and are willing to step over those who are most in need to reach their self serving goals.
Unfortunately, in modern America, survival of the fittest translates to survival of the richest and the psychologically strongest. Corporate America preys on vulnerable citizens whose fast paced lives, competing roles, mounting stress and growing isolation crave comfort and solace. That comfort is cleverly packaged and readily available in the form of fast food, illicit and prescribed drugs and other short term, incomplete solutions to complex problems that require a far more planned, comprehensive approach. In fact current short term, incomplete methods of managing depression are creating far more problems than they are solving and are rapidly leading to a vast American healthcare crisis. Willingness to look beyond the medical and corporate paradigms to test and develop effective, comprehensive and accessible depression treatment is not on the immediate horizon. Because depressive phenomena render those affected unable to advocate for themselves, they must depend on the humanity and advocacy of others. This inhibition of grass roots fund raising efforts has prevented funding for depression comparable to that generated for other chronic diseases such as breast cancer and the HIV spectrum.
We are at a critical juncture in the evolution of healthcare delivery in this country whereby deficiencies in services to treat depression accentuate several aspects of societal dysfunction. Systems are being overwhelmed by vast increases in serious yet preventable diseases. Depression and other common psychiatric symptoms linked to maladaptive behaviors such as smoking, overeating and sedentary lifestyles are subsequently linked to etiology of major chronic illnesses including obesity, type 2 diabetes, cancer and heart disease to name a few. Diagnosis with a chronic medical illness exacerbates the severity of psychiatric symptoms, further inhibits lifestyle changes and interferes with utilization of prescribed medical treatments. This process is circular, self perpetuating, profound and costly in financial and human terms. It speaks to the rising prevalence of chronic medical conditions, mental health problems, soaring health costs and futility of technological and therapeutic advances in the absence of comprehensive mental health services based on research with diverse populations and combined with consistent, standardized professional education.
We must address the serious issues raised by objectifying the selection of research priorities (that would make depression a frontrunner in terms of resource allocation). Medical and technological advances must be synchronized to keep pace with systematic, equal increments in new knowledge regarding management of the sequelae to those advances. The development of an over arching conceptual framework to guide research and related services initiatives must be applied at the federal level, extend to regional, state and community based funding agencies and to as many private foundations as are willing to participate. Central coordination of activities is paramount so knowledge development, and subsequent service initiation so that program evaluation and modification can proceed in an orderly fashion. An example of a coordinated research/service/evaluation initiative with potential to address the gaps in depression services will be summarized under the following heading:
Operation MATCH-UP: Maximizing Access To Comprehensive Health Care for Underserved Populations. Programmatic initiatives under this or any framework must incorporate consistent, operational elements to guide all programmatic components including purposive, need and evidence based research, subsequent multimodal clinical trials, evaluation and modification of treatments on the basis of the gap between research efficacy and translational utility in a variety of real world, clinical settings. Key elements of the Operation MATCH-UP initiative targeted to address the rising incidence and prevalence of depression in modern society will be described below.
ELEMENT 1. Innovative strength based assessment and management. Mental health screening and evaluation will incorporate individual strengths into treatment planning. Individual strengths will be quantified along specific dimensions to inform individual treatment and to quantify the potential range of treatment response/clinical improvement. Strength based assessments are in sharp contrast to the problem oriented standard of care that pervades current depression treatment practices. For example, schools typically manage childhood depression when severe symptoms manifest as behavioral problems and result in disruption of daily routines. These disruptive behaviors are subsequently managed by consulting or staff mental health personnel who prescribe pharmacologic agents alongside law enforcement officials who utilize punitive approaches. The discussion of alternative actions, motivations, and/or exploration of more positive coping strategies is not typically explored. While a compassionate, inquisitive approach could stimulate positive communication, problem solving and supportive relationships among peers and superiors, most schools maintain authoritative approaches that identify student deficiencies and seek to eliminate them without question. The strength based, problem solving approach described could model desired behaviors, promote communication and positive relationships among teachers, school administrators, health providers and law enforcement officials and offset the self perpetuating negativity that pigeon holes students with refractory behavioral problems. Institutions that serve individuals with diverse problems, talents and needs could benefit, in general, by adopting assessment and intervention strategies that reinforce individual strengths and promote interventions that extend beyond unitary pharmacologic treatments. Further, caregivers/parents often feel pressured to medicate unruly children/patients and are subsequently faced with a barrage of media reports that relate controversy as well as life threatening side effects associated with the drugs they are administering. This can make caregivers susceptible to ongoing stress and put them at risk for development of psychiatric problems themselves. There is an unmet societal obligation to support these vulnerable individuals, to determine their specific needs, provide then with guidance and link them to appropriate services.
ELEMENT 2. Community, Professional, and Family caregiver education and support: Future research, clinical and community based initiatives must address the societal ignorance that fosters substandard practices, isolation of those managing mental health problems and an unsympathetic stance by unaffected individuals. For example, high schools with community service requirements could develop and evaluate outreach activities between selected high school students and a variety of vulnerable patient groups such as the institutionalized and homebound depressed elderly and school children at risk for developing mental health problems. Such programs could stimulate compassion for these typically ostracized, underserved communities and be used to address issues of fear, stigma and isolation. Further, career interest could be fostered, stereotypes challenged and charitable interest promoted simultaneously.
ELEMENT 3. Identification of cost effectiveness and delineation of strategies for creating financially self-sustaining, community based mental health programs: Data regarding the cost effectiveness of depression treatments must accompany quality outcome data. Services must be affordable, and demonstrate sustainability beyond funded research protocols. Although cost savings associated with comprehensive mental health services can usually be documented, if divergent treatments and/or outcomes are compared across studies, cost effectiveness may not be apparent. Further studies often ignore the importance of longitudinal data collection over a time period sufficient to reveal clinical improvement. Similarly depression research usually excludes collection and analysis of cost data over time. Therefore a treatment may seem prohibitive based on expense when short term quality and cost outcomes are examined and long term outcomes excluded. Outcomes such as impact of a treatment on long term functional improvement, ability to hold a job over time, etc could support treatments that could improve the economic and social welfare of a society rather than being viewed exclusively in narrow, individual terms. These methodologic flaws are common in psychiatric intervention research and must be remedied. Future studies must also address the conflict of interest that arises when psychiatric intervention studies are sponsored by parties with a financial interest in the treatment being tested (such as pharmaceutical companies that sponsor drug trials). Finally, the generalizability of treatments applied in research environments must be considered for their realistic application in real world clinical settings within the context of the restraints imposed by managed care companies and the ability of busy understaffed clinics to administer standardized, labor intensive treatments.
Adoption of the preceding framework has great potential to provide structure and direction to future research on depression and clinical initiatives aimed at providing quality, cost effective health care to the increasing numbers of depressed Americans whose mental health problems interfere with quality of life and receipt of comprehensive health services.