Doctors seek new tools to aid in depression treatment

With strategies to diagnose and initiate the treatment of depression in the primary care setting firmly established, researchers are increasingly looking for ways to improve patient adherence to therapies and measure their effectiveness.

Last month, a study published in the Canadian Medical Assn. Journal suggested that a brief tool could be used by primary care physicians to quantify the severity of depression and assess whether the chosen treatment was working.

"Depression is in many ways like hypertension or diabetes. It's a chronic disorder," said Roger S. McIntyre, MD, lead author and assistant professor of psychiatry at the University of Toronto. "But clinicians don't know how to measure it."

The paper found that seven questions from the 17-question Hamilton Depression Rating Scale -- HAMD-17 -- could assess effectively whether those being treated for major depression were getting relief from prescribed therapies. This scale could be administered by a primary care physician in three to four minutes and was found to be as effective as the more arduous 17-question version that is rarely used outside research or specialty settings.

"The tool was too big and too unwieldy for a family physician," said Dr. McIntyre, who is also head of the Mood Disorders Psychopharmacology Unit at the University Health Network in Toronto.

Experts praised the concept, particularly since the authors have placed the tool in the public domain, making it readily accessible, and said that additional tools to monitor depression were welcome.

"It's an excellent idea, and the questions are reasonable," said Barbara Yawn, MD, a family physician and director of research at Olmsted Medical Center in Rochester, Minn.

Still, some question whether it bests what is already available. Many primary care physicians use the "Patient Health Questionnaire-9" or PHQ-9, which can be administered by the patient, while the HAMD-7 requires a trained clinician.

"I agree with the premise, but I disagree with the approach that they took to do it," said Michael S. Klinkman, MD, director of primary care programs for the University of Michigan Depression Center in Ann Arbor. "[The HAMD-7] still requires a skilled interviewer to carry out and takes three to four minutes. That's pretty precious time."

But while some researchers are looking for new tools to monitor patient progress, others are looking for ways to keep patients in treatment.

The American Academy of Family Physicians' National Research Network recently launched a study of postpartum depression. This study is funded by the Agency for Healthcare Research and Quality, and the goal is to go beyond diagnosing and initiating treatment to determine what it takes to keep women treated as long as they need to be.

"Just identifying the people and beginning treatment doesn't make any difference to outcomes," said Dr. Yawn, principal investigator. "Most will discontinue treatment within the first six weeks."

These efforts to improve the quality of depression care in the primary care setting come in the wake of the increasing realization that this disorder may be more prevalent in this setting than in others.

Most recently, preliminary results from a large multisite study attempting to evaluate various treatment options published in the December Acta Psychiatrica Scandinavica found that chronic major depression was associated with less education, lower income, a lack of private insurance, greater overall illness burden and unemployment. It also was associated with being cared for by a primary care physician rather than a mental health specialist.

"These patients have greater socioeconomic disadvantages and may have less financial resources to be able to seek out psychiatric care," said William Gilmer, MD, lead author and medical director of the Asher Center for the Study and Treatment of Depressive Disorders at Northwestern University Feinberg School of Medicine in Chicago.

But researchers also recognize that access to specialty mental health care might be more complicated than increasing the patient's resources.

A paper in the Journal of Adolescent Health this month examining the experiences of depressed children and teens found that from 1995 to 2002, antidepressant use increased slightly. Counseling declined significantly. Researchers are concerned that these drugs might be overused, particularly in light of the black-box warning regarding a possible link to suicidality in this age group, added by the Food and Drug Administration last year.

"We're not saying that doctors should avoid prescribing antidepressants for kids, but we are pointing out the potential for inappropriate use," said Jun Ma, MD, PhD, lead author and a research associate at the Stanford University School of Medicine Prevention Research Center.

Others, though, said this might be less an issue of overuse of medicine than indicative of a lack of access to mental health services. Child and adolescent psychiatrists are in short supply. Insurance coverage also might not include mental health services.

"When you cannot find someone to do the therapy, you resort to the tool that you have," Dr. Klinkman said.

Many also suspect that the use of antidepressants in this age group may have declined in the wake of recent controversies, an occurrence that has concerned physicians. The American Medical Association Council on Scientific Affairs issued a report earlier this year calling for these drugs to continue to be available in conjunction with prudent clinical judgment.

"The question isn't simply how many kids are getting one treatment or another," said David Fassler, MD, clinical associate professor of psychiatry at the University of Vermont College of Medicine in Burlington, who testified at the FDA hearings on the issue. "But are the right kids receiving the most appropriate and effective treatment possible?"