Depression: Getting the Treatment You Need

A diagnosis of depression shouldn't feel like a life sentence. Doctors and mental health professionals have more tools than ever to help: Antidepressant drugs can lift your mood, and counseling or psychological therapy can help you understand what's responsible for your dark thoughts -- and how to get rid of them. Equally important, such treatment can help renew your love of life and encourage a more positive attitude.

Missed opportunities

Unfortunately, like many depressed people, you may be missing out on relief. Even if you see a doctor, that doesn't guarantee you'll get the help you need. For one thing, doctors often fail to ask patients about feelings of depression, according to recent surveys. And when they diagnose depression, they may not offer an effective treatment for it. For example, one study of patients diagnosed with severe depression published in the Archives of General Psychiatry found that one-third didn't receive a prescription for antidepressants.

The September 2006 issue of the Harvard Mental Health Newsletter reports that surveys show one-third to one-half of depressed patients who see a primary care physician aren't accurately diagnosed. (To be fair, many doctors are allotted only about 15 minutes to spend with each patient, and some insurance plans have made mental health services a separate program that rarely involves the primary care physician.) In one study reported by the newsletter, 80 percent of patients who suffer from depression say they hadn't seen a counselor, therapist, or any other mental health professional within the last year.

Sometimes even when doctors throw out a lifeline, depressed patients fail to take hold. As reported in a 2006 issue of Clinical Opinion in Psychiatry, roughly 40 percent of people with depression or other mood disorders fail to stick to the treatments recommended by their doctor. Many people distrust antidepressants and psychological therapy, and may even be reluctant to accept a diagnosis of a mental illness. As a result, prescriptions go unfilled, pills go untaken, and appointments to see counselors or therapists get missed.

Over the years, Brian Haynes, MD, PhD, a diabetes specialist and chief of the health information research unit at McMaster University in Ontario, Canada, has worked with many depressed people who failed to take their medicine for depression, diabetes, or other conditions.

"People who are depressed feel hopeless," he says. "They feel that they don't have the ability to control their own health. They may not even be eating. So how can they be expected to take their medication?"

Even if you're determined to get healthy, depression can make it much harder than usual to stick to a plan. As reported in the Archives of Internal Medicine, people with depression often feel unfocused or scatterbrained. It's no wonder, then, that some depressed people forget to take their medicines. According to the Harvard Mental Health Newsletter, nearly 50 percent of depressed patients in primary care quit taking their medicine within three months -- months earlier than the minimum recommended time. At a time when more than 20 million American adults suffer from depression each year, doctors are realizing that they need to dramatically change their approach to treating it. But they can't do the job alone. If you've been diagnosed with depression, there are things you can do, too.

Recognizing depression early on

Since many patients feel too embarrassed or hopeless to bring up the subject, some experts urge doctors to screen for depression as frequently as they screen for high blood pressure and high blood sugar. Here's a short but effective two-question screening that's widely used:

  • Over the past two weeks, have you felt down, depressed, or hopeless?
  • Over the past two weeks, have you felt little interest or pleasure in doing what you usually do?

A number of studies suggest that almost all patients who need treatment for depression will answer "yes" to at least one of those questions. Look at the questions again and answer them for yourself. If you said "yes" to either one, maybe it's time to tell your doctor you could be depressed -- and ask for help.

Two-way conversations

If you're depressed, you need to have a clear, two-way conversation with your doctor about the condition and possible treatments. As reported in Current Opinion in Psychiatry in 2006, the conversation should go far beyond instructions for taking pills. For starters, your doctor should ask you about your attitude toward medicine. Different drugs can cause different side effects, and you should have the chance to talk about your concerns and preferences. You may not mind if a drug causes weight gain or a loss of interest in sex, but for other patients, that could be a deal-breaker. If your doctor doesn't ask you these questions, you have the right to bring them up yourself.

Drugs can differ in other ways: Some are more expensive than others, and some may require more than one dose every day. Again, you may need a chance to explain your preferences. Doctors should also discuss psychological therapy, including who can provide it, how it helps, and how many sessions may be necessary.

When all of the important information is on the table, you and your doctor can work together to choose the right treatment. According to the Current Opinion in Psychiatry report, patients are much more likely to get the treatment recommended by experts and less likely to relapse if they felt involved in decisions.

"Depressed patients often sense a loss of control over their lives, so it is especially important to encourage them to make their own decisions and give them a stake in their treatment," according to the Harvard Mental Health Newsletter. Tell your doctor that you want to be involved in the process.

Doctors are also paying more attention to a possible communication gap or "disconnect" between themselves and their patients. As the Harvard newsletter reports, most doctors responding to one national survey say they give patients detailed instructions about medicines, stressing that they need to keep taking the drug even after symptoms improve. But patients surveyed tell a different story, saying their doctors hadn't talked to them about that. And although most doctors recalled that they made treatment decisions jointly with patients, patients disagreed. Patients added that their doctors didn't pay attention when they complained about the side effects of medicines.

A study published in the November 2006 issue of the Journal of General Internal Medicine, however, suggested that both patients and doctors may be suffering from selective memory: Researchers posing as patients with depression secretly recorded interviews with internists and family physicians who agreed to be audiotaped as part of the study. The "patients" found that a full 85.3 percent mentioned side effects, while 96.1 percent discussed the drug's purpose and 90.7 percent mentioned the name of the medicine. On the other hand, the study found plenty of room for improvement in terms of adherence:

Physicians rarely advised the "patients" to continue to take the medicine even if they were feeling better, or to continue to take the medicine unless they checked with a physician. "This study shows that patients who are prescribed antidepressants for the first time may leave the physician offices without important drug information," particularly information associated with improved adherence to therapy, the authors concluded.

It's probably fair to say that both sides could listen and communicate better. If depression has made it hard for you to concentrate, consider asking your doctor if you can record your conversations; that way, you can play them back if you need to. You might also take a close friend or family member along as your patient advocate: He or she can take notes and help you remember what was said in the session.

A patient advocate can also help you remember your follow-up appointment. Far too often, the back-and-forth between the doctor and patient ends as soon as the patient walks out the door. A study published in an issue of Psychiatric News found that only 20 percent of patients diagnosed with depression and prescribed antidepressant medicine had sufficient follow-up care in the following three months.

Experts recommend at least three visits with a physician or mental health provider during the first 12 weeks after diagnosis, but try to schedule your first appointment between weeks 2 and 4 to discuss both possible side effects and symptoms improvement. Doctors should also keep in mind that when patients wait too long in between appointments, it's easier to stray from the treatment plan. Many experts recommend that doctors closely monitor depression in the same way they manage diabetes, heart disease, and other chronic illnesses.

New approaches to depression

You shouldn't have to manage depression on your own. In 2006, the Depression and Bipolar Support Alliance, a support group for depressed patients and their families, urged doctor offices to provide on-call case managers and mental health specialists who could talk to patients any time of day -- something that may be difficult to implement unless doctors are reimbursed for such services. The Alliance also urged doctors to immediately refer patients to a therapist or counselor.

Medical professionals should also continue reaching out to patients long after that first appointment. A simple phone call can encourage patients to take their medicines and keep their appointments. As reported in the Journal of the American Board of Family Medicine, depression symptoms are more likely to improve when patients get regular follow-up calls from a nurse.

Meanwhile, new advances in medicine may make it easier for you to stick to your treatment. As reported in Current Opinion in Psychiatry, patients in the near future may be able to receive a steady flow of medicine from an implant, much as many women currently receive hormones for birth control.

Taking control

If you're depressed, staying healthy may take extra effort. You should definitely take your medicine as prescribed and keep all of your appointments with your doctor or mental health professional, even if you start feeling better. During those appointments, be sure to get answers to any lingering questions or doubts about the treatments. According to Haynes, even small doubts can become a huge obstacle to treatment.

Getting help for your depression is probably the best thing you can do for your health. Not only will your mood improve, but you'll discover new strength, energy, and motivation to take care of yourself.

References

Interview with Brian Haynes, MD, PhD, a diabetes specialist and chief of the health information research unit at McMaster University in Ontario, Canada

Harvard Mental Health Letter. Improving Care for Depression: New Approaches to Managing a Chronic Illness. September 2006.

Byrne N et al. Adherence to treatment in mood disorders. Current Opinion in Psychiatry. 2006. 19: 44-49.

Meyers BS et al. Predictors of early recovery from major depression among persons admitted to community-based clinics. Archives of General Psychiatry. August 2002. 59: 729-735.

Solberg LI et al. Follow-up and follow-through of depressed patients in primary care: The critical missing components of quality care. Journal of the American Board of Family Practice. November-December 2005. 18(6): 520-527.

DiMatteo MR et al. Depression is a risk factor for noncompliance with medical treatment. Archives of Internal Medicine. July 24, 2000. 160: 2101-2107.

National Institute of Mental Health. Depression. 2000.

Young, Henry, et al. Types of Information Physician Provide when Prescribing Antidepressants. Journal of General Internal Medicine. Volume 21, Page 1172-1177. November 2006.

Moran, M. Depression care compromised by lack of follow-up. Psychiatric News. March 19, 2004. Vol 39 No 6.

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