Specialist editorial – Major depressive disorder
Professor Anthony Hale
Professor of Psychiatry at the University of Kent
In the treatment of major depressive disorder (MDD) most patients are treated in primary care. The boundary between MDD appropriately treated in primary care and secondary care has been defined by the National Institute for Health and Clinical Excellence (NICE) using the stepped care approach where GPs manage even severe depression, except where the patient is treatment resistant, recurrent, atypical and psychotic, and those at significant risk of suicide or self neglect.
In my experience most patients who have successfully been treated for MDD with antidepressants, nevertheless say that if they became depressed again, they would prefer talking therapy. Reasons given are the side-effects of antidepressants, the belief that tablets are second best, belief in addiction potential (>50% explicitly said so) and the lack of belief in depression as a ‘medical’ condition.
Cognitive behavioural therapy (CBT) has been shown to be superior to counselling, and suggestions that practice counsellors be retrained in expert CBT skills are understandable. Patients’ preference for talking therapies must thus be interpreted as preference for effective talking therapies. These have been underprovided in recent years, with long waiting lists. Government has attempted to rectify this with finances and training intended to provide 10,000 new psychological therapists by 2013, the Improving Access to Psychological Therapies (IAPT) programme, focusing mainly on CBT.
Ineffective treatments prolong the duration of untreated depression (DUD) which raises the risk of treatment resistance and chronicity. It has been known for some years that outcome and response to treatment for depression and anxiety is related to chronicity of symptoms and to duration of untreated symptoms.
GPs are coming to recognise the varied ways in which depression can present. Qualitative differences between more severe and milder MDD are often related to larger numbers of
biological symptoms, many of which relate to circadian rhythm disturbances. In a national survey, GPs saw sleep disturbance and low mood as the most important depressive symptoms, and that >80% of depressives reported sleep disturbance and that 50% of patients presenting with sleep disturbance turned out to be depressed.
Modern antidepressants offer patients the option of the convenience of tablets with very few side-effects, and in primary care, I predict that many will opt for this rather than the time and hard work associated with CBT.