Autodidact: self-taught



by V. L. Craven

“The Real Depression Story” by Peter D. Kramer 8 January, 2010
001. …it is well-established that antidepressants work for dysthymia chronic or frequently recurring minor depression…
002. …some overviews have found Paxil to be among the least effective of the antidepressants.
003. …antidepressants do little to end isolated episodes of mild depression…
004. While Paxil did moderate depression, the drug’s greater effect was in changing personality. The principal outcome for subjects who responded to Paxil was a decrease in “neuroticism”–essentially, emotional vulnerability in the face of adversity. The patients with less neuroticism seemed to be protected from future bouts of depression. They also became more extraverted. In other words, Paxil was less good at ending episodes of depresson than at making patients resilient via personality change. A second intervention tested, a form of psychotherapy, showed the reverse. It had more effect on depression and less on personality.
005. If we look only at the two recent studies, we might draw puzzling conclusions about antidepressants. They help with acute severe depression. They help with chronic minor depression. And yet they do little for acute, isolated bouts of minor mood disorders.
006. The American Psychiatric Association is updating its diagnostic manual. Very likely it will make a move toward “dimensional” modes of illness, in which a large number of factors will be taken into account in the course of making a diagnosis. For depression, the factors may include social anxiety and emotional fragility, so that personality traits linked to mood may enter in out concept of the disorder.
007. …are patients with minor (but not chronic) depression prescribed antidepressants? Older surveys found that they were not. In practice, all depression is undertreated. To me, the real news of the month is another study, from the University of Michigan in the Archives of General Psychiatry . It found that only one in five Americans with depression has received even one adequate course of treatment in the past year. The criteria for adequate treatment are modest: 60 days of antidepressant with four doctor or nurse visits over the year or (for talk therapy) four mental health visits lasting 30 minutes or more.
008. Here are some of the study’s findings. The average person diagnosed with depression had severe depression. Thirty-four percent of the depressed received any medication, with 11 percent receiving adequate medication. The comparable figures for psychotherapy were higher (44 percent any; 19 percent adequate). Only 9 percent of patients got the gold standard, adequate drug treatment with adequate psychotherapy. If you look at minority groups, like blacks and non-Puerto Rican Hispanics, the numbers are cut in half, almost no one gets good care.
009. To me, that’s the story that matters. Most depressed people don’t get evaluated; most who are evaluated don’t get treated; and most who are treated are treated poorly. As for whether medication helps with minor depression, that question may be less important than another one. If we were to treat all patients well–if with the mildly or moderately depressed we were to start with psychotherapy and then, if that doesn’t do enough, weigh other options–in that situation, ought we to consider antidepressants?

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