Treating depression today

By Charles Bensenhaver, M.D.

About 17.5 percent of adults will suffer from major depression in their lifetime. While depression is more widely recognized and treated today, that statistic has remained consistent for the past 20 to 30 years. The protocol for treating depression hasn’t changed much either since the development of medications like Prozac in the mid-1980s revolutionized depression care. Since that time, there have been very few new medications developed for the treatment of depression.

The best treatment for patients with major depression remains a combination of psychotherapy and medication. Some can get by with one or the other, but studies continue to show that combination therapy is the best approach. That has been the standard for many years.

While the protocol has remained the same, it has been frustrating that medications have not changed much in recent years. However, we do have new augmentation strategies, in particular with regard to second-generation antipsychotic medications. In 1998, it was predicted that by today we would have individualized genetic treatment of depression, but that is not yet the case. It remains too early to know if individualized genetic-based treatments would be effective and at this time, it would be cost prohibitive. In short, we are still using the same molecular theory that we did 60 years ago.

New Developments

Still, without new pharmaceutical developments, there are new approaches and programs available for adults suffering from depression to get the help they need to get well.

In the last decade, we have developed a much better understanding and acknowledgment of patients with bipolar disorder. Many years ago when we had a patient that we thought was not responding to depression treatments, they may not have been correctly diagnosed with bipolar disorder. This was a common error because bipolar patients are depressed more than they are manic or hypo-manic. Today, we know that treating bipolar patients as depressed can actually make them worse.

More than 60 percent of patients who suffer from mental illness never see a mental health professional. I interact with a number of primary care physicians in the course of my day at the hospital. They have become very skilled at recognizing the symptoms of depression in their patients. In milder cases of depression, primary care physicians can treat patients quite effectively. However, if the case is complicated by suicidality or chemical dependency, referring the patient for more specialized care is the best choice. In my experience, most primary care physicians recognize when their patients need additional support. My rule of thumb is, “if it doesn’t feel right, call us.”

Evaluating Patients

When evaluating patients, it remains important to take a detailed history. There are also scales and tools available to assist with making a diagnosis. Typical questions to ask patients include:

Have you experienced post-partum depression?
Did you have early onset of depression?
Do you have a family history of mood disorders?
Are there any time periods when your mood swung to the other extremes?

I ask those very questions to any patient I see for the first time to be develop a better understanding of his or her history and to be sure we are not dealing with bipolar disorder.

Today, we know that 60 percent of patients with major depression also suffer from an anxiety disorder and vice versa. Fortunately, pharmacologic treatments for depression are also generally effective for anxiety. In short, the complicated nature of the major depression, bipolar and anxiety disorders requires multiple approaches to care.

Continuum of Care

Though medications haven’t changed much in the past decade, insurance coverage and practices have changed, which has in turn changed how we deliver care to our patients. In the last 10 years, insurance coverage practices have forced us to put sicker patients in less intensive levels of care. For example, some patients who may be candidates for inpatient care have to be placed in more limited programs. This change has led to the development of specialized programs and the creation of more options to make treatment affordable and most effective.

At Our Lady of Peace, we have found that providing multiple levels of treatment gives patients a continuum of care and the best chance for recovery. Our Peaceful Transitions outpatient program for adults with severe mental illness includes full and half day programming is designed to prevent patients from inpatient hospitalization. The program is designed for patients with severe and persistent mental illness.

The healing process begins with medical care coupled with the development of healthy coping skills and therapy provided by licensed clinicians. Transitions is a unique program that serves a wide variety of patients. The program also allows for a dual track for those who have severe mental illness coupled with chemical dependency.

We also offer an adult partial hospitalization program through which patients come for treatment five days a week and see a physician two to three times each week. The program can also be phased down based on the patient’s needs and improvement.

For older adults, Peace Geriatric Services specializes in treatment for seniors for symptoms related to dementia, depression/anxiety disorders, chronic mental illness and substance abuse. Our physicians and staff specialize in working with geriatric patients and are available every day to include families in care during treatment and to assist with resources for successful discharge planning.

Patients who complete one of our treatment programs are also invited to attend Aftercare, which is a support group for former patients. In Aftercare, patients can assist each other with the transition from treatment and receive support and affirmation for using new coping skills. Aftercare groups are provided free of charge for patients for a period of up to six months from their time of discharge.

Treatment options for patients who suffer from depression and other forms of mental illness are always advancing. For example, we’ve seen research to suggest that while it is a newly developed treatment and not yet widely used, Transcranial Magnetic Therapy has shown to improve depression symptoms. Transcranial Magnetic Therapy stimulates the nerve cells in the region of the brain involved in mood control and depression. Innovative and non-invasive treatments like this promise a bright future for treatment options.

Although the treatment of major depression today is based on the same theories as it was in 1950s when the first antidepressant drug was introduced, care today has adapted and changed to meet the specialized needs of patients and overcome the challenges often caused by limits to healthcare coverage. One thing that remains constant is that there is hope for patients with major depression. Using a combination of medication and psychotherapy, the outcomes remain promising.

Charles Bensenhaver, M.D. is psychiatrist and medical director of Our Lady of Peace in Louisville, Ky.