Depression: Help From The Off

19. September 2017

Around one in ten GP patients show signs of depression. Only the most minor percentage of them undertake initial therapy. A new treatment procedure has online support as its focus, which provides help before a severe depression develops.

A state of despondency does not always have to result in a depression – but it can be a harbinger. It is unclear here where a severe depression begins and whether a slight depression or depressive mood already needs to be treated.

The boundaries between subclinical depression and classic unipolar depression are fluid and vary according to the guidelines which are valid at any given time.

Neglected depression pre-stage?

Around one in ten of any GP’s patients show signs of depression, but only the smallest number of them follow a path to a specialist. More than half of depressed people, according to Detlev Ganten, president of the World Health Summit, receive no appropriate treatment, because the disease is not taken seriously by doctors and patients. But even for those who make it to therapy problems can arise, especially in serious cases: antidepressants help less than a third of these patients in the long term.

The active ingredients or their derivatives have generally already been in use for more than half a century, do not act specifically and help only a percentage of the patients. Depression is the disease with the longest duration over a lifetime. Bearing in mind that treatment is insufficiently effective, prevention is all the more important. The treatment of even only minor depression symptoms should be started before the disease develops into a serious form.

Subclinical depression, sub-threshold depression or dysthymia – anyone using these keywords in a search will only come across a few studies on it. In the last two years, however, two major investigations appeared in the Journal of the American Medical Association (JAMA) which describe the psychotherapeutic treatment of the disease before it becomes really dangerous. While the British-American study recruited patients of an elderly age, researchers from the University of Erlangen-Nürnberg (Germany) looked at participants of an average age of about 45 years.

Encouragement via weekly telephone call

As can be seen in the first of the two studies, the “collaborative care” model has asserted itself in the Anglo-American sphere, in which psychotherapeutic care is integrated into primary care. A “care manager” supervises the treatment under the supervision of a psychotherapist. In this study involving 705 patients with low grade depression over the age of 65, Simon Gilbody from the University of York and his colleagues compared normal GP care with the integrated care approach. In this case, it consisted of weekly telephone calls from the care manager.

In the first part, specialists and patients met personally, after which the patient was encouraged in a half-hour verbal conversation to make more social contacts and to reduce depressive periods through hobbies and other activities. Both after four months and after one year, the scientists measured the effect of this short-term treatment by means of a questionnaire.

Compared to the control, the patients treated in this way scored 1.3 points better on a nine-point scale after four months. What’s more, the difference remained stable after one year. The effect size, which was calculated to be 0.3, matches the results of similar studies involving cases of severe depression. The risk of developing a severe depression decreased here by a third. The comparatively uncomplicated procedure reduced not only the risk, but also helped reduce anxiety and functional limitations in everyday life which result of mild depression. In a comment on this study Kurt Kroenke from the Regenstief Institute in Indianapolis said that this short and economical behavioural activation procedure appears to be well suited to prevent the transition to a more advanced form of the disease.

Self-help program online

This is the result also arrived at by the second German study involving over 400 participants using an interactive online program instead of the phone. Here too, the study managers compared a “normal” web-based psychotherapeutic self-help program with personal treatment using an online trainer, which included elements of cognitive behavioural therapy.

The participants were given home assignments, to which the supervisor responded accordingly and individually assessed. A total of six 30-minute sessions are supposed to help patients, ideally being done twice per week. Twelve months later, the researchers analysed the results via structured telephone interviews with the participants to find out whether the light depression had become a severe depression.

Not all want a therapy

Using the simple self-help program this is what happened to 41 out of 100. If the online trainer actively participated in the therapy, the rate dropped to 27 percent. The calculated Hazard-Ratio is 0.59. The intensive program can therefore prevent one in six patients getting severe depression within a year.

Nevertheless, figures of 28 and 41 percent respectively appear to be rather high risk factors for the exacerbation of mild depression. Other studies report figures of about 10 to 20 percent. This is possibly however also due to the participant selection. The study intake included only questioning persons with functional limitations in everyday life, and who were selected from the files of a large statutory health insurance. In the end, there is no consensus definition for subclinical depression, so that the baseline is also different between the studies.

Not everyone experiencing gloomy thoughts, albeit over a long time, wants therapy at all. Only with the appropriate resolve is the success of such a procedure truly noticeable.

Prevention pays off

The question of whether it is more useful to wait when long term mild symptoms of depression are present, or to start right away with therapy, cannot be answered at the moment due to lack of data. Results so far indicate that antidepressants do not function better than placebo in patients with subclinical disease. To this extent, the psychotherapeutic method seems superior to the pharmacological one. The question of whether web-based therapy is also more economical than conventional treatment has been the subject of recent studies.

In their articles in the Journal of Medical Internet Research, the authors emphasised the clear economic advantage of web-based treatment: they calculated their additional costs of the intensified and personalised therapy per patient for the 200 participants to be around 136 euros for the six-mentioned sessions. The majority of this goes to the coach, who spent a total of about three hours per participant. On the other side of the equation, there are the additional depression-free years and the quality of life obtained, as determined from the standardised interviews with the participants.

A person with depression has to wait around three months on average before he or she gets a therapy place with a specialist. Then it takes another quarter of a year until the actual treatment begins. In order to prevent the progress of the initial phase of a depression from happening, it is therefore necessary to adopt early measures.

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Medicine, Psychiatry

1 comment:

Marsha Carter
Marsha Carter

I find that good nutrition goes a long way in helping with depression. America today is living on junk food expecting their vitamins to get them through. It doesn’t work. How to get fruits and vegetables into a person? Juice Plus is the answer I have found.

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