New York Times commentary by Dr. Peter Kramer, psychiatrist and author of Listening to Prozac: Patients are beginning to treat depression with respect. Whether their doctors are ready to do so is less clear.
… A study in the current issue of The Journal of the American Medical Association finds that almost six in 10 Americans who suffer depression seek treatment in a given year. A decade ago, the figure was one in three.
But the researchers found that only about 40 percent of patients received what standard guidelines consider ‘minimally adequate medical treatment.’ Those criteria call for a month of antidepressants monitored in four office visits or eight half-hour counseling sessions.
There is a long tradition in general medicine of ignoring or undertreating depression. But a second article in JAMA suggested reasons that the pattern may change. That report described the largest study of psychotherapy ever conducted, sponsored by the National Heart, Lung and Blood Institute.
The study is a response to evidence, developed over the past decade, that depression, like diabetes and hypertension, is a risk to the heart. By middle age, studies show, depression triples or quadruples the risk of cardiac death. The most acute danger comes in the wake of heart attacks. After a first attack, depression raises the risk of recurrence dramatically. NY Times
Kramer discusses the intimate relationship — probably far more complex than you would have expected — between depression and cardiac disease in some detail. Antidepressants likely reduce cardiovascular morbidity and mortality by a combination of mechanisms both related to and distinct from their antidepressant actions.
Quite rightly. But, on the other hand, at this year’s American Psychiatric Association annual meeting, I noticed a new marketing trend in the big pharmaceutical companies’ exhibit booths. And, whenever I notice a new marketing trend in pharmaceuticals, I assume it has much much more to do with preserving or enlarging profits than with scientific accuracy… Increasingly, the promotional gospel is that depression is a systemic disease rather than simply one of the mind. Emphasizing its connection with bodily fatigue, chronic pain, gastrointestinal distress, immune dysfunction, cardiovascular effects etc., while probably scientifically accurate, seem to serve primarily profit-making goals for their manufacturers by enhancing the likelihood that an antidepressant will be prescribed in a given instance.
As I have often written here, for the past several decades they have attempted, and largely succeeded, in enlisting internists and other primary care specialists as prescribers of psychoactive drugs, displacing mental health specialists to the detriment of the patients and then ignoring the contribution of that trend to the adverse outcomes. This effort will be facilitated if non-psychiatric practitioners are persuaded to conceptualize their patient’s depression as a physical disease, and if they can envision prescribing an antidepressant as potentially addressing their patients’ vague bodily complaints they find so vexing and time-consuming a part of a primary care practice.
In addition to facilitating the shift of antidepressant prescribing to non-psychiatric practitioners, this emphasis on depression as a physical ailment can be expected in a similar manner to shift the overall response to depression toward the medication solution and away from non-medical solutions such as psychotherapy… or simply adequate time and attention in the busy internist’s schedule.
I am not suggesting that Kramer is a knowing tool of the pharmaceutical industry. But if the zeitgeist is changing we ought to recognize the full range of contributing influences.
