Too Important
Depression may be the second or third most prominent cause of medical disability in the world. Yet overall treatment effectiveness is modestly better than placebo.
Why?
The reasons range from guild restrictions to blinkered thinking. Almost everything considered in depression treatment lies in two categories – drugs or talk therapies.
But:
1. Since at least the 90s it’s been known that antidepressants are not much better than placebo for new cases of depression (they are good anti-anxiety drugs, though.) Recent resurveys showed that 94% of drug company studies demonstrated antidepressant superiority to placebo – but only 51% when the unpublished ones were counted.
2. Psychotherapy efficacy has been established for over 50 years – particularly for cognitive-behavioral ones. Yet just as with drug studies, the most recent international review of manual based studies found them considerably less effective when unpublished research was included.
So what’s next? Supplements? Diets? Ketimine?
Regretfully, the old ways of attacking the problem have mainly failed. It’s time to recognize depression as the final common pathway of innumerable insults to body and mind – from loss of love to parathyroid tumors. Systemic illnesses need systemic treatments – particularly when present treatments are so unimpressive.
Next, we have to look at wide based measures of effectiveness – lots more than agglomerated symptom scores. Depression afflicts economic, social and community life much as it does psychological well-being. We’re talking about one of the biggest impediments to health in the world. If health is the goal, social, economic, and community results need consideration – both for outcomes and as treatments.
Plus we also have to look at new approaches – particularly cheap ones – that might help. If most present treatments are not much better than placebo, even small incremental improvements may prove worthwhile.
Finally, we have to look at combinations, just as is done in hypertension or oncology studies. There are plenty of drugs + psychotherapy studies out there. Affects of net based treatments, CBT for example, in combination with others, need to be studied.
To open things up, here are some approaches that might be considered:
1. Light. Dan Kripke and others have demonstrated that sunlight – or lightboxes – aid depressive treatment. Sunlight is free. Lightboxes don’t cost a lot.
2. Exercise – Many studies argue exercise is effective for “mild to moderate” depression. It’s time to ask how well exercise works – particularly combined with other treatments. And we’ll need to compare periods of high intensity only, high intensity interval training, versus simple walking or strolling.
3. Job – no job. People who are depressed often find work therapeutic – until they can’t perform. If they lose their jobs, the results are often catastrophic – for their health, their economic survival, their families and communities. Studies to see if depressed people can be kept in jobs, and whether health for themselves and families improves, needs more research.
4. Sleep. Rachel Manber and others have strongly suggested normal sleep helps people get undepressed much faster. Sleep has to be looked at not just as a result, but as a major treatment variable – especially when non-pharmacologic therapies show good results.
5. Body clocks – light has different effects on treatment effectiveness with time of day. Is the same true of anti-depressants? Many depressed patients find their circadian rhythms are off – what happens when they’re put back in synch, particularly in conjunction with more regular sleep? Simple chronotherapies need to be considered as part of depression treatment.
6. Nature – Many studies argue time in nature improves mood. Plus, it is often easy to obtain sunlight and physical activity at the same time.
7. Bacteria – yes, bugs. The very recent studies of kids with different bacterial populations experiencing less asthma should remind people that animal studies show adding lactobacilli to genetically identical mice markedly cuts their ability to get depressed. That does not mean yogurt will prevent depression. Yet it’s clear the microbiome is intimately connected with the brain.
For the body is an information system – or rather a series of information systems. Depression affects almost everything we do – from eating to moving to sleeping. Its causes are systemic.
And its treatment should be systemic. For an illness that causes economic damages in the hundreds of billions you would think new approaches might get major research funding.
They generally don’t. Partly it’s the silos caused by guilds – psychologists and psychotherapists versus psychiatrists; partly the effects of larger players – the enormous influence of drug companies on treatments, and of insurance companies on what gets paid for. Yet the bigger issue remains literally a systemic one – seeing the body as a system. And understanding health as well-being – with its physical, mental, social and spiritual components.
The goal of medical treatment should be to improve health – full physical, mental, social and spiritual well-being. That should also be the goal of depression treatment. Presently we don’t treat depression well. Perhaps if we look to physical, mental, social and spiritual elements both for treatement as outcomes – we can do a lot better.
We need to.
