Treatment of depression: Drugs alone are not enough

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The treatment of depression is undergoing a trend toward drugs and away from talk therapy, a change fueled by the cost-cutting fervor that has taken over the medical care system in the last few years. Drugs are seen as more efficient and cost effective than psychotherapy.

Drugs also fit in with the role of the primary care physician who is the health professional most likely to encounter people with untreated depression. Unfortunately, studies have shown that depression often goes unrecognized by the family doctor. But things are changing as a result of educational campaigns and the introduction of new drugs like Prozac that are easier for the general practitioner to prescribe (See "Anti-depressant Drugs," page 6).

Now that the drugs-alone trend is in high gear, a new RAND study has concluded that a combination of counseling and medication, though initially more expensive, is not only the more effective way to treat depression but also cost saving in the long run (JAMA, 4 January 1995).

The new study, which is a decision analysis based on published evidence, also warns against the prescription of minor tranquilizers to people suffering depression. These drugs (e.g., Valium and Xanax) can successfully treat severe anxiety but not depression. Family doctors rely too heavily on the prescription of sedating tranquilizers, according to RAND, an independent California-based nonprofit research institution.

Untreated Depression
People with untreated depression are high users of the medical care system, making more visits to doctors than those who are not depressed. They seek care for physical complaints, such as fatigue, insomnia, and/or muscle aches, and are usually unaware that they are depressed. At its most severe, depression can cause people to lose interest in activities that used to be pleasurable, to cease normal functioning altogether, and/or to commit suicide. Descriptions of such signs are at the heart of all educational campaigns aimed at training family doctors to recognize depression. The risk of recurrence is high: 50% after one episode of depression, 70% after two episodes, and 90% after three episodes.

The relatively low efficacy of drugs alone for people with depression had already been determined by the Agency for Health Care Policy and Research (AHCPR) which co-sponsored the new RAND study with the National Institute for Mental Health. In 1993 the AHCPR conducted its own review of the published studies and concluded: "The scientific evidence indicates that over 50% of depressed outpatients who begin treatment with antidepressant medication experience marked improvement or complete remission of their depressive symptoms." And this about the role of psychotherapy: "Scientific evidence indicates that several forms of short-term psychotherapy (cognitive, interpersonal, or behavioral) are effective in treating most cases of mild or moderate depression."

The RAND decision analysis was commissioned by AHCPR to expand upon its 1993 findings in order to determine how to get the best return on the health care dollar--a critical issue to managed care-style health plans, which generally limit access to specialists by requiring members to see their primary care physician initially.

"This was not a study to test the difference between counseling and medication," explained coauthor Kenneth B. Wells, M.D., senior researcher at RAND and professor of psychiatry at UCLA School of Medicine, in a telephone interview. "We found that the combination of medication and counseling is associated with the largest improvements in functioning outcome," he said, referring to the depressed person's ability to get back to day-to-day activities. "Counseling [alone] has nearly as large an effect on outcome, but we did not have the precision to tell whether counseling or medication was the more powerful effect."

Dr. Wells and his coauthor, economist Roland Strum, Ph.D., looked at the three types of health professionals who treat depression and found that psychiatrists were most likely to deliver appropriate care, i.e., the combination of drugs and counseling. But care delivered by a psychiatrist is at least four times as expensive as care provided by a general practitioner, and a non-physician therapist (psychologist) is at least twice as expensive as a general practitioner.

Interestingly, Drs. Wells and Strum found that as long as counseling was provided along with the antidepressant drug, it didn't matter which professional provided the care. Although the proportion of general practitioners who counseled their patients for an average of 11 visits was small (only 20%), the outcome for their patients was similar to that of the psychiatrist and non-physician therapist.

Ability to Function
"In fact, there really aren't any outcome studies like ours [which involved participants treated] in the typical practice settings. Earlier studies are all based on highly selected patients [treated] in research settings," said Dr. Wells. "This [the RAND study] is the first to show that if patients get the right treatment, their ability to function is affected."

Isn't it true that most depression studies are short-term, though depression treatment can last for months, even years? "Yes, clinical studies usually last only six weeks, sometimes six months," answered Dr. Wells. "Ours was a two-year outcome study. Typically, studies do not examine functioning, although this is changing; they just look at changes in the present symptoms like mood, appetite, concentration, loss of interest in pleasurable activities, and guilty rumination. But what we were interested in is whether people can go back to work, do their housework, mow the lawn, etc."

Only a minority of seriously depressed people, according to RAND, are currently receiving appropriate treatment.

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