From the Editor
How helpful do people find treatment for depression?
This question is broad but new work (drawing on WHO surveys) ambitiously attempts to answer it across different countries, including some that are low income.
In the first selection, we consider a paper from JAMA Psychiatry. Meredith G. Harris (of The University of Queensland) and her co-authors report on WHO data. The good news? Many people do find treatment for depression helpful. The bad news? Many providers are needed for people to believe that they had received helpful treatment.
In the second selection, we look at a new essay by Dr. Richard A. Friedman (of Weill Cornell Medical College). Writing in The New York Times, he discusses the pandemic and the possibility of “a mental health epidemic of depression and anxiety.” Dr. Friedman argues that we are seeing mass boredom, not a rise in disorders like depression. While he can’t fully rule out that the pandemic will bring about an increase in mental health problems, he writes: “let’s not medicalize everyday stress.”
“Findings From World Mental Health Surveys of the Perceived Helpfulness of Treatment for Patients With Major Depressive Disorder”
Meredith G. Harris, Alan E. Kazdin, Wai Tat Chiu, Nancy A. Sampson, Sergio Aguilar-Gaxiola, Ali Al-Hamzawi, et al.
JAMA Psychiatry, August 2020
Major depressive disorder (MDD) is associated with the number of years lived with disability globally, affecting approximately 5% to 6% of people worldwide each year and 11% to 15% of people for a lifetime. The high burden of MDD exists, in part, because many people do not receive effective care. Many studies have defined potentially effective care for MDD using objective criteria, usually in terms of the number of professional visits and either the type of professional seen or the type of intervention received. However, patient-centered definitions can also help to identify needs that are not fully met by treatment and in turn can inform policy and service responses to address these needs. Thus, a patient’s evaluation of the helpfulness of treatment is an important measure that can be collected directly and efficiently and, when assessed in population surveys, can help fill a knowledge gap about treatment outcomes at a population level.
In epidemiologic studies, approximately 55% to 75% of adults seeking help for depression or other mental health needs say they received treatment or professional contact that was at least somewhat helpful. With some exceptions, available studies of the helpfulness of depression treatment have focused on treatment received during a short term among prevalent cases rather than taking a longer-term perspective…
A patient’s pathway through care may involve contact with numerous professionals, each of whom may or may not provide treatment that the patient considers helpful, and this experience may consequently encourage or discourage future attempts by the patient to seek care either in the current episode or in subsequent episodes… Here, we examined the prevalence and factors associated with perceived helpfulness of treatment and of its 2 main components based on retrospective reports obtained in a cross-national, representative community sample of individuals with a lifetime history of depression treatment.
So begins a paper by Harris et al.
Here’s what they did:
- They examined the results of a series of epidemiologic surveys of adults based on the World Health Organization World Mental Health surveys.
Seventeen surveys were conducted in 16 countries; 8 surveys in high-income countries and 9 in low- and middle-income countries. Countries included Australia, Spain, and China. The United States and Canada weren’t surveyed.
The dates of data collection: from 2002 to 2003 (Lebanon) to 2016 to 2017 (Bulgaria).
- Participants included those with a lifetime history of treated MDD. The survey included the WHO Composite Diagnostic Interview (CIDI).
- With regard to helpfulness and depression: participants were asked several questions. For example, they were asked about the age at onset and then: “Did you ever in your life talk to a medical doctor or other professional about your (sadness/or/discouragement/or/lack of interest)?” Also: they were asked about their age and when they first spoke to a professional (if they did). (Professionals were defined broadly to include psychologists, counselors, spiritual advisors, acupuncturists, and others.) Respondents who said that they had talked to a professional were then asked “Did you ever get treatment for your (sadness/or/discouragement/or/lack of interest) that you considered helpful or effective?” Both those that had found treatment and those that didn’t were asked about the number of professionals they had spoken to
- “Data on socioeconomic characteristics, lifetime comorbid conditions (eg, anxiety and substance use disorders), treatment type, treatment timing, and country income level were collected.”
- Statistical analyses were done.
Here’s what they found:
- Across all countries combined, 37.2% (n = 7 448) of adults with lifetime DSM-IV MDD reported ever being treated, and of those treated, 68.2% (n = 2 726) reported ever obtaining treatment that they considered helpful.
- Demographics: the (mean) age at first depression treatment was 34.8 years, and 69.4% of participants were female.
- Treatment probability was approximately twice as high in high-income countries (47.1%) compared to low- and middle-income countries (22.5%).
- In terms of the number of professionals seen: “Survival analysis showed that the cumulative probability of receiving helpful treatment increased from 30.6%… after the first professional seen to 58.1%… when patients persevered in trying a second professional after unhelpful treatment from the first, with 93.9%… projected to receive helpful treatment if they persevered in trying up to 10 professionals after earlier ones were unhelpful.” But the cumulative probability of persisting through 10 professionals was only 21.5%
- Perception of helpfulness was associated with several factors, including patients being older and highly educated.
“Findings from the present large, community sample are encouraging in that more than two-thirds of those people seeking help for lifetime MDD eventually received depression treatment that they perceived as helpful. However, our findings also suggested that this percentage might increase markedly if patients persisted in help-seeking after earlier treatment failures.”
A few thoughts:
- This is an interesting study.
- Combining low and middle income nations with high income nations was particularly interesting.
- Not surprisingly, people in low and middle income nations were less likely to receive care that was perceived as helpful.
- Would the results be different if the participants included Canada or the United States?
- The big finding: “patients with MDD obtain treatment that they consider helpful might increase, perhaps markedly, if they persisted in help-seeking after unhelpful treatments with up to 9 prior professionals.” That’s a big number.
- The paper runs with an editorial by Dr. Mario Maj (of the University of Campania), “Helpful Treatment of Depression – Delivering the Right Message.” Dr. Maj is somewhat cool to the paper, especially the definition of health professionals. He notes that “all types of ‘help-seeking’ were interchangeable” – except that they aren’t, he writes. “If a patient encountered 2 nurses, 1 psychologist, and 1 psychiatrist at an outpatient unit, these may have been counted as 4 consecutively contacted professionals. Furthermore, if a spiritual advisor referred a patient to a general practitioner, who referred the patient to a psychologist, who referred the patient to a psychiatrist who provided successful treatment, the former 3 contacts were probably counted as ‘unhelpful.’” (This criticism is fair, but not necessarily overly damning.)He continues thoughtfully: “In summary, treatment of depression may well be ‘a trial and error enterprise,’ as Harris et al emphasize. However, the likelihood that it is perceived as helpful will increase if we make clear that the qualification of the treatment professional, a formulation of the management plan based on the characteristics of the individual patient, and adequate attention to the therapeutic alliance and to the patient’s desired outcomes are among the main factors involved.”
The editorial can be found here:
The JAMA Psychiatry paper can be found here:
“Is the Lockdown Making You Depressed, or Are You Just Bored?”
Richard A. Friedman
The New York Times, 21 August 2020
There has been a lot of talk recently about how the coronavirus pandemic has unleashed a mental health epidemic of depression and anxiety.
That the pandemic has amped up our stress levels is certainly true. Indeed, there have been a few highly publicized surveys showing that levels of general psychological distress are on the rise. But I worry that calling this a wave of clinically significant depression or anxiety might be premature. What if we’re just bored out of our minds?
Many of my patients who have struggled with depression and anxiety have, surprisingly, not experienced flare-ups of their psychiatric illnesses over the course of the past few months. They do, however, say that they feel bored and frustrated. Lots of friends and colleagues, too, say that life has taken on a stultifying quality of sameness.
The truth is that we don’t know yet whether what we’re seeing in these surveys will bloom into a full-fledged mental health epidemic. The surveys are, after all, quick snapshots of how we feel during a relatively brief period in time. Their results need to be corroborated by follow-up studies.
Richard A. Friedman
So begins an essay by Dr. Friedman.
“[L]ittle of what we’re experiencing now is pleasant. But it’s worth remembering that boredom is a normal emotional state that we shouldn’t conflate with a serious illness like depression. That doesn’t mean, however, that we shouldn’t address it.”
He continues, drawing a contrast between boredom and depression:
“Clinical depression is characterized by an inability to experience pleasure, insomnia, loss of self-esteem and suicidal thinking and behavior, among other symptoms. In boredom, the capacity for pleasure is totally intact, but it is thwarted by an internal or external obstacle – like being quarantined. (Boredom also produces none of the other symptoms of depression.)”
Dr. Friedman makes a few observations about boredom:
- “Researchers asked a group of people to spend just 15 minutes in a room and instructed them to entertain themselves with their own thoughts. They were also given the opportunity to self-administer a negative stimulus in the form of a small electric shock. Strikingly, 67 percent of men and 25 percent of women found being alone with their own thoughts so unpleasant that they chose negative stimulation over no stimulation.”
- “As Luke Fernandez and Susan J. Matt wrote recently in Salon, the word boredom did not enter the lexicon until the mid-19th century. Before that, tedium was an expected part of life. It was only with the rise of consumer culture in the 20th century that people were promised nearly continuous excitement; boredom was the inevitable consequence of such unrealistic expectations.”
- “Being bored might feel intolerable, but, unlike clinical depression, it will never seriously impair your function or kill you. While depression calls for treatment, boredom is a normal state.”
“I do not mean to suggest that the pandemic might not cause an increase in serious mental illness; that’s certainly possible. I’m simply saying that it’s premature to make that judgment. In the meantime, however, let’s not medicalize everyday stress. And let’s not dread boredom, but try to use it to our good.”
A few thoughts:
- This essay makes important points.
- We should appreciate the clarity of his writing for a general audience. (Yes, I made a similar comment about Dr. Satel’s prose a couple of weeks ago.)
- In both the academic literature and the popular press, much has been made of surveys arguing that symptoms of depression and anxiety have increased during the pandemic. But symptoms aren’t the same as full disorders. Dr. Friedman’s distinction between boredom and mental illness is excellent. In some ways, he is making similar points to the ones made by Drs. Patten and Kutcher in the pages of Policy Options. “Mental health is a very broad term and encompasses many different emotional, cognitive, and behavioural states. It does not simply mean ‘feeling good all the time.’ Indeed, negative emotional states in appropriate situations are necessary to drive adaptation and are a normal component of mental health.”
The Patten and Kutcher essay was considered in a past Reading:
The full Friedman essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.