Tag: depression

Reading of the Week: Depression and Measurement-Based Care (Depression: Week 1 of 3)

September 10, 2015 /

Major depression is common, leading to marked suffering for patients and families and causing physical and mental disability, with a substantial economic burden. Although major depression is prevalent across different cultures and effective pharmacological and psychosocial interventions are available, low remission rates in clinical practice are discouraging. Poor outcomes are related to inadequate dose and duration of pharmacotherapy, poor treatment adherence, high dropout, and frequent as well as unnecessary medication changes. In addition, inconsistency of treatment strategies among clinicians is common. Even in current, guideline-driven practice, there are often wide variations in clinicians’ behaviors, resulting in practice bias rather than a tailored and individualized treatment algorithm.

So opens a new paper that has a large goal: trying to reduce that “wide variation” and improve patient care.

This week’s Reading: “Measurement-Based Care Versus Standard Care for Major Depression: A Randomized Controlled Trial With Blind Raters” by Tong Guo et al., just published online (and ahead of print) by The American Journal of Psychiatry.

Find the paper here:

http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2015.14050652

Here’s a quick summary: big study, big journal, and big implications for depression management (and, yes, your patients). In a head-to-head comparison, patients did better when depression management included an algorithm for medications rather than regular psychiatrist care. Continue reading

Reading of the Week: Depression: Is There an App for That?

July 9, 2015 /

Depression is a serious, common, and recurring disorder linked to diminished functioning, quality of life, medical morbidity, and mortality. There has been a 37.5% increase in health life years lost to depression over the past two decades. Depression was the third-leading cause of global burden of disease in 2004 and the leading cause of burden of disease in high- and middle-income countries. It is projected to be the leading cause globally in 2030. While effective treatments for depression are available, they are underused. Barriers to treatment include geography, socioeconomic status, system capacity, treatment costs (direct and indirect), low mental health literacy, cultural beliefs, and stigma. A 2010 study found that 75% of primary care patients with depression in urban areas could identify more than one structural, psychological, cultural, or emotional barrier to accessing behavioral treatments. The rate was substantially higher in rural areas.

So begins a new paper that considers an old problem – the difficulty of patients accessing mental health care.

But this paper is different. It considers a modern approach to access: smartphone and tablet applications (or apps) for depression. And it’s not just the topic that is so modern with this week’s Reading. Consider: the paper was published in a new journal, JMIR mHealth and uHealth, available only on-line, and focused on the very modern topic of mobile health. (This journal is a spin-off of JMIR, the Journal of Medical Internet Research, itself a relatively new journal, which boasts an impact factor of 4.7 in 2013.)

This week’s Reading: “Finding a Depression App: A Review and Content Analysis of the Depression App Marketplace” by Nelson Shen et al. In it, the authors seek to shed light on a poorly studied area. As they note early in the paper, despite the incredible popularity of apps, only one recent systemic review looked at depression apps, and included just 4 papers. And so, Shen et al. consider apps for depression, drawing out common characteristics and purposes.

This is, then, an important topic. The potential here is great: with so many of our patients empowering themselves with apps, those with depression could potentially access good information, screening tools and even treatments such as CBT.

What did Shen et al. find in their paper? It’s best summarized by the old Roman phrase caveat emptor (let the buyer beware). Continue reading

Reading of the Week: The New Yorker Essay on De Troyer (and Carter v. Canada)

June 25, 2015 /

In her diary, Godelieva De Troyer classified her moods by color. She felt “dark gray” when she made a mistake while sewing or cooking. When her boyfriend talked too much, she moved between “very black” and “black!” She was afflicted with the worst kind of “black spot” when she visited her parents at their farm in northern Belgium. In their presence, she felt aggressive and dangerous. She worried that she had two selves, one “empathetic, charming, sensible” and the other cruel.

She felt “light gray” when she went to the hairdresser or rode her bicycle through the woods in Hasselt, a small city in the Flemish region of Belgium, where she lived. At these moments, she wrote, she tried to remind herself of all the things she could do to feel happy: “demand respect from others”; “be physically attractive”; “take a reserved stance”; “live in harmony with nature.” She imagined a life in which she was intellectually appreciated, socially engaged, fluent in English (she was taking a class), and had a “cleaning lady with whom I get along very well.”

So begins this week’s reading, an essay by writer Rachel Aviv that was just published in The New Yorker.

It’s a moving and tragic story of a woman who struggles with low mood. If she dreams of fluent English and a cleaning lady, her life takes a turn for the worse: after a breakup, she “feels black again.” Loss and estrangement replace hope and love. After years of struggling, the near elderly woman ultimately chooses to end her life. But she doesn’t die by her own hand; she dies in a clinic at the hands of a physician. To us Canadians, this is a story that is both familiar – involving psychiatry and medications – and unfamiliar – euthanasia and state-sanctioned doctor-assisted suicide.

De Troyer’s life and death occurs an ocean away, in Belgium. But, in light of a recent Supreme Court of Canada ruling in Carter v. Canada, a question to ask: how will doctor-assisted suicide reshape psychiatry in this country? Continue reading

Reading of the Week: The Case For Publicly Funded Therapy

June 4, 2015 /

It’s 4:30 on a Friday afternoon at her Sherbrooke, Que., clinic and Marie Hayes takes a deep breath before opening the door to her final patient of the day, who has arrived without an appointment. The 32-year-old mother immediately lists her complaints: She feels dizzy. She has abdominal pain. “It is always physical and always catastrophic,” Dr. Hayes will later tell me. In the exam room, she runs through the standard checkup, pressing on the patient’s abdomen, recording her symptoms, just as she has done almost every week for months. “There’s something wrong with me,” the patient says, with a look of panic.

Dr. Hayes tries to reassure her, to no avail. In any case, the doctor has already reached her diagnosis: severe anxiety. Dr. Hayes prescribed medication during a previous visit, but the woman stopped taking it after two days because it made her nauseated and dizzy. She needs structured psychotherapy – a licensed therapist trained to bring her anxiety under control. But the wait list for public care is about a year, says Dr. Hayes, and the patient can’t afford the cost of private sessions.

Meanwhile, the woman is paying a steep personal price: At home, she says, she spends most days in bed… Dr. Hayes does her best, spending a full hour trying to calm her down, and the woman is less agitated when she leaves.

But the doctor knows she will be back next week.

So begins an article from The Globe asking a simple question: should we publicly fund psychotherapy? In this week’s Reading, “The case for publicly funded therapy,” Erin Anderssen argues yes.

http://www.theglobeandmail.com/life/the-case-for-publicly-funded-therapy/article24567332/

Anderssen’s piece opened the The Globe and Mail’s excellent new series on mental health, which covers everything from the potential of technology to the search for biological markers. Continue reading

Reading of the Week: Depression and Employment

May 14, 2015 /

I want to get back to work… I want to get back to my life.

A patient recently made this comment to me. Before his depression, he had thrived at a government job and taken great pride in his work. (He showed me iPhone pictures of an event he had helped organize which was keynoted by the premier.) But in the cloud of depression, he left his job, and worried that he would never have another one.

This raises a simple question: how do you get patients like this back to work?

It seems like an obvious question to ask – and very relevant one. After all, many people with depression are off work, or have left the workforce altogether. A Towers Watson report considered disability in North America; mental health issues (typically “depression, anxiety and stress”) contribute to 78% of short-term and 67% of long-term disability claims in Canada. Let’s put that in perspective: for short-term disability, cancer was well under half that.

Yet if the burden of illness is great, little has been written about interventions to get patients with depression back to work. A 2008 Cochrane review identified only 11 randomized controlled trials (RCTs) on interventions aimed at reducing work disability in workers with major depressive disorder (and just four studies including work functioning as an outcome measure). A more recent Cochrane review considered 13 randomized controlled trials; only three studies, for example, looked at antidepressant therapy.

That’s why this week’s Reading is so interesting. “Gains in employment status following antidepressant medication or cognitive therapy for depression” by Jay C. Fournier et al. compares drug management with psychological interventions (CBT). Continue reading

Reading of the Week: Economics and Mental Illness

May 7, 2015 /

For John Mooney, it was a career highlight. In March the Irish cricketer took a crucial catch that gave his team the victory in a World Cup match and eliminated the higher-ranked Zimbabwe. But afterwards the Zimbabwe Herald, a daily paper with links to Zanu-PF, the thuggish ruling party, claimed that Mr. Mooney had lied when he said that his foot had not been touching the boundary, meaning the catch should have been disallowed. The article cited previous interviews in which the sportsman had spoken frankly about his long battles with drink, depression and suicidal thoughts. Under pressure, it claimed, a “man of such a character” could not be trusted to have “the honesty, let alone the decency” to tell the truth.

John Mooney, cricketer, Ireland “player of the year” (2010), and a man with depression

So begins this week’s Reading.

The essay provides an excellent summary of the impact of mental health on our society and our economy. It also notes reasons for hope. Indeed, Mr. Mooney’s story is moving: after the Zimbabwe Herald attack, fearing that others may be reluctant to talk about their mental illness in light of his harassment, Mr. Mooney chose to publicly speak about his battle with depression. The article notes:

The reaction was heartening. Messages and thanks are still coming in.

This essay is readable and concise. “Out of the shadows: The stigma of mental illness is fading. But it will take time for sufferers to get the treatment they need” is a must read. Here’s the surprise: it was published in an economics magazine.

Welcome to 2015, where thoughtful analysis on mental health issues isn’t just for the psychiatry journals anymore. Continue reading

Reading of the Week: Zen or Zoloft? Mindfulness vs. Meds for Relapse Prevention in Depression

April 30, 2015 /

Depression typically has a relapsing and recurrent course. Without ongoing treatment, individuals with recurrent depression have a high risk of repeated depressive relapses or recurrences throughout their life with rates of relapse or recurrence typically in the range 50–80%.

So begins this week’s Reading (which is attached). As is so often the case, the journal writing is understated.

50-80%. Wow.

Having been in practice for some years, many stories come to mind when considering this statistic.

Here’s one: a young woman with a challenging childhood who pulled her life together, kept an unplanned pregnancy, and then tried to do everything right for herself and her daughter. In her late 20s, she fell into a deep depression, attempted suicide, and had a long admission. And, after work on the inpatient unit and in the outpatient department, she returned to her life: free of symptoms, working full time, raising her daughter. Feeling well, she stopped her citalopram, and became sick again (and with an employer keen on her termination because – and this sounds like a 19th century novel – “she told me I look dead on the outside”).

It’s easy to say that she should have stayed on her medications. But many of our patients don’t. The reasons vary – the side effects are too strong, the concept of medications is unappealing, etc. – but the end result is so often the same.

What then are non-medication options for maintenance in patients with depression? This week’s Reading offers an interesting answer: mindfulness-based cognitive therapy.

Continue reading

Reading of the Week: Can Crowdsourcing Treat Depression?

April 23, 2015 /

Social networks aspire to connect people, which is a noble but naive goal. When we uncritically accept connection as a good thing, we overlook difficult, important questions: Are some forms of virtual communication more nourishing than others? Might some in fact be harmful? Is it possible that Facebook, for instance, leaves some people feeling more lonely? No one knows for sure. We tend to build things first and worry about the effects they have on us later.

Robert Morris is taking the opposite approach. Starting with the desired effect of helping people deal with depression, he developed Panoply, a crowdsourced website for improving mental health.

So begins this week’s Reading.

This is not your typical selection. Though the disease discussed is depression, the treatment involves social networks, not sertraline. The article is well written, but it doesn’t appear in the pages of World Psychiatry but Wired. The article details therapy, but with a focus on apps, not Adler. CBT is important, but crowdsourcing is talked about more than cognitive distortions.

Welcome to psychiatry in the 21st century.

Continue reading