State of the art in the care of the depressed patient


ABSTRACTBackground: Depression continues to be a major cause of morbidity and mortality. Depression is a common debilitating illness that can happen to anyone, at any age, and to people of any race or ethnic group. Females are more vulnerable than males; one out of four women may have depression sometime during their lifetime. Despite the wide range of people who suffer from this serious disorder and the associated high risk of death from suicide, only 20 percent are currently receiving treatment. Moreover, it is well recognized that depression greatly contributes to fatality associated with heart disease. The 1990 Global Burden of Disease Study ranked depression as the fourth leading disease burden worldwide as measured by life-years lost to disability, and it is projected to be ranked as the second leading disease burden by the year 2020. In light of these statistics, there is a clear need to address the impact of this condition and to develop new methods to adequately diagnose and treat those who suffer.Objective: The objective of this paper is to highlight recent developments regarding treatment and care of the depressed patient.Method: A review of recent literature on the neurobiology of depressive disorder, and its reflection on the care and treatment of the depressed patient formed the matrix for this paper. Neurobiology of depression: Evidence from neuroscience, genetics, and clinical investigation demonstrate that depression is a disorder of the brain. Modern brain imaging technologies are revealing that in depression, neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly, and that critical neurotransmitters are perhaps out of balance. Genetics research indicates that vulnerability to depression results from the influence of multiple genes acting together with environmental factors. Studies of brain chemistry and of mechanisms of action of antidepressant medications continue to inform the development of new and better medical and psychotherapy treatments. STAR*D, a large study funded by the National Institutes for Mental Health, found that less than half of patients got completely well after a single antidepressant was taken, and although more patients got well once they were switched to another medicine, the proportion of those who got better decreased each time a person had to switch to another medication. Treatment of depression: Recent advances in treatment have occurred for patients with mood disorders, these include: pharmacotherapy, combined psychotherapy pharmacotherapy, and novel physical therapies. The focus of new drug development reflects a shift from serotonin specificity to combine or specific noradrenergic activity. The efficacy of sequencing cognitive therapy after anti-depressant treatment in patients who were partially remitted was examined recently by Paykel and colleagues. The cumulative relapse rate was reduced significantly from 47% in the clinical management control group to 29% in the group that received 16 sessions of cognitive therapy. Conclusion: Improved recognition, treatment, and prevention of depression are critical public health priorities. The administration of combination of treatment interventions and dual reuptake inhibitors are likely to ensure early response and prevention of relapse. Recovery of function ought to be the target of any treatment plan.