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LETTERS: Sharon J Williams Depressed patients need more than drugs and psychiatrists BMJ 2003; 326: 338 [Full text]

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Depressed patients need an improved system of care

Anthony T Frais   (9 February 2003)

GP perspective

andrew j hart   (11 February 2003)

Flying blind in managing endogenous depression

Richard G Fiddian-Green   (13 February 2003)

Depressed patients need an improved system of care 9 February 2003
Anthony T Frais, Company Director leeds ls7 8eb Send response to journal: Re: Depressed patients need an improved system of care	Ms.Williams states that she does not believe a psychiatrist can make an accurate diagnosis in one visit. She also believes that depressed patients are not functioning well enough to clearly communicate a full and accurate account of their illness. But the skilled and caring psychiatrist would put pertinent questions to the patient in order to arrive at a diagnostic conclusion. I suspect Ms. Williams conclusions may have arisen from a system housing psychiatrists who (as in this country) are under pressure of work or in some cases,may lack psycho-analytical skills. Even with a correct diagnosis, anti-depressant treatment is notoriously empirical. The patient who responds well to the first anti-depressant treatment is indeed fortunate. Less fortunate are those who have been prescribed anti- depressants which have an adverse effect and even give rise, as Ms. Williams describes, to suicide ideation. The problem with patients experiencing suicidal ideation is that they may assume that that this effect is part and parcel of the illness and may continue taking the drug in the belief that sooner or later,it will bring the promised relief. The reality is that the drug is more likely to exacerbate the depth of the depression. Doctors are now wholly reliant on patients reporting these symptoms. Even here, it is possible that the more 'street-wise' patients will answer negatively to the question of self-harm so as to to preserve their liberty i.e not to be sectioned. Ms. Williams finally concludes that there is insufficient back up support for depressed patients. There is some truth in this, but what should be done? With the increasing stress of modern life,the number of patients presenting with depression will surely rise.Depression should therefore be recognised as an illness that needs its own well defined system of treatment and care. Patients who present to their G.P. should be refered to a psychiatrist. However, in practice, a quick appointment may not be possible.Whilst waiting for this appointment (and indeed beyond that)an interim solution to this would be to place the patient immediately into a mainstream ongoing care system.This would mean the patient attending a day centre staffed by mental health nurses. The attendance would be at a frequency to be determined. Here the patient can not only be monitored, but will have the benefit of being in the care of trained staff who have sufficient time to offer sympathetic advice on such matters as how to come to terms with an illness whose prognosis cannot be accurately predicted, that anti-depressants should be considered as only palliative, and other meaningful pieces of information and advice. It is known that a number of deeply depressed people do not report to their G.P. as they may wish to keep this fact 'off the record'. But if it were known that a well defined and efficient and sympathetic treatment system for depression was in place, it may encourage those who remain at large to come forward. Competing interests:   None declared
GP perspective 11 February 2003
andrew j hart, gp greenview surgery,129 hazeldene road, northampton,nn2 7pb Send response to journal: Re: GP perspective	It is barely worth responding to the casual dismissal of the family doctor's ability to deal with depression. Many of our consultations are with depressed patients and it is an essential part of our work to be able to help such people. This may be entirely by the GP or with involvement of a member of a mental health team but would certainly not require a psychiatrist in every case - even if they were available. It is a shame that there is still much ignorance amongst different medical professionals. I am sure that the situation in Canada is similiar to the UK and that such responses should be more carefully considered. Competing interests:   None declared
Flying blind in managing endogenous depression 13 February 2003
Richard G Fiddian-Green, None None Send response to journal: Re: Flying blind in managing endogenous depression	The pathogenesis of endogenous depression has not been clearly established. It might be the product of a metabolic energy deficit which may amongst many adverse efects impair the release of neurotransmitters and the replenishment of neurotranmitter pools. In which case medication may be making patients much worse, compounding the severity of the underlying metabolic defect, causing other chronic diseases and increasing the likelihood of dying from acute illnesses. Most drugs that are being used to treat endogenous depression have the potential to impair mitochondrial oxidative phosphorylation (1). Drugs that stimulate the release of or enhance the effects of neurotransmitters may do so indirectly by increasing the demand for energy from ATP hydrolysis beyond the capacity for resynthesis by oxidative phohsporylation in a timley manner. A situation analogous to glutamate neuro-excito-toxicity may thus be created. 1. Concerns about prescribing antidepressants Richard G Fiddian-Green bmj.com/cgi/eletters/325/7366/701#25874, 28 Sep 2002 Competing interests:   None declared