What about treatments for depression?
Let’s move into the management,
now that we've defined it.
First of all, we can’t forget about talk therapy.
Cognitive therapy is just as effective as prescription
treatment for patients with depression
and it has the added benefit of giving patients a skill set.
Since depression is frequently a
recurrent illness for many patients,
it's important to have some kind of framework
and a skill set that you can use to
fight not just this episode of depression,
but the one that will happen in four years from now,
eight years from now.
And cognitive therapy gives patients that skill set.
And that, medication cannot do.
What about another little-known and
underused regimen for depression,
but they can be highly effective?
What about exercise?
So, this is – there is a systematic review,
37 clinical trials of exercise and depression.
Overall, exercise was found to have
a moderate effect on depression.
And there was in trials with higher quality,
slightly less effect, but still significant.
And it was maintained over the long term.
And I think the most interesting thing from this
review was that there were seven trials,
which compared exercise and psychological therapy,
no difference between them.
Four trials compared exercise and pharmacological therapy,
no difference between them.
This tells me that, if nothing else,
exercise should be part of the treatment
regimen for patients with depression.
Maybe it’s not the only treatment that’s recommended,
but it should be part of the regiment
and highly recommended to patients
because it also, we know,
has benefits for stress,
anxiety and, of course,
bodyweight metabolism as well.
In terms of specifically medications
that fight against depression,
the general rule is that when you
give one of these medications,
about a third of patients will
experience remission of depression,
a third will get a response
without achieving remission,
and a third really experience no benefits.
So, the rule of the thirds with antidepressant therapy
has been true for quite some
time if you look across clinical trials.
Some things to note, some high-yield facts
regarding medical therapy for depression.
Serotonin norepinephrine reuptake
inhibitors are slightly more effective
than selective serotonin reuptake inhibitors (or SSRIs)
in the treatment of depression,
but that increased efficacy is counterbalanced
by higher risk of adverse events.
And so, therefore, it's really what your
patients can take over time and tolerate
and what they do well on is the
most important factor in determining,
which is the right antidepressant for your patient.
And that’s why,
I think, the most critical question for patients –
because depression is frequently recurrent,
have they tried anything in the past?
If they took a certain medication in the
past and it worked for them then,
it's highly likely that it’s going to work for them now.
And so, that's the first thing to consider.
And also, that question allows you to identify
that maybe the patient tried drug X, Y or Z
and had side effects or didn't work,
and, therefore, those can be crossed off the list.
You’re going to use something different.
But, yeah, always ask about
that past history of depression
and particularly what treatment they used.
Hopefully, they will remember it
or you have it in your record.
Remember that antidepressant
therapy is not as effective
for mild forms of depression.
Sometimes those patients just do
better with talk therapy alone.
I try to move them more
towards that type of treatment.
But for severe depression,
that's where antidepressant therapy
has its best record of efficacy.
And once you initiate an antidepressant,
I tell patients that we are going to
recommend that you continue this treatment
for at least six months
and preferably 12.
We know that discontinuing the drug,
which many patients do,
two or three months into treatment, they feel better,
they don't know why they're taking this drug
anymore because they feel cured,
once they discontinue the
drug before six months,
there's a very high rate of recurrence.
So, they should really commit to taking it for a year.
And I talk about that before I even
write the initial prescription
just to get that commitment from a patient.