Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
GPs are not so bad at diagnosis
- Tony Kendrick (26 February 2008)
-
Need for Specialist Opinion in Recurrent Depression
- Michael S Small (3 March 2008)
-
Good management of depressed adults
- Hiske J. van Ravesteijn, Lieke J. A. Franke, Tim C. olde Hartman, and Peter L.B.J. Lucassen (4 March 2008)
-
Nothing mentioned, nothing gained.
- Ross A. Dunne, Professor Declan McLoughlin, Research Professor of Psychiatry, St. Patrick's Hospital & Trinity College Dublin. (13 March 2008)
-
Re: Good management of depressed adults
- Ricardo Gusmão (1 April 2008)
|
|
|||
|
Tony Kendrick, Professor of Primary Medical Care University of Southampton SO16 5ST
Send response to journal:
|
Timonen and Liukkonen state that, according to cross-sectional studies, 50-70% of patients with depression in primary care remain undetected. This attack on GPs’ ability to recognise depression is out of date and should not go unchallenged. Studies have shown that firstly, many of the missed cases have relatively mild symptoms, that lie only just above the threshold on screening measures for depression, which have dubious clinical significance and may represent false positives since all diagnostic measures have rating errors1. In addition, cross-sectional recognition rates are obtained from a single 10-minute consultation, and usually exclude patients whom the GPs have already recognised as depressed. The article fails to acknowledge studies showing that many ‘missed’ patients are diagnosed correctly at subsequent visits. Kessler et al found that, although many patients with depression did not receive a diagnosis at a single consultation, most were given a diagnosis at subsequent consultations or recovered without a general practitioner's diagnosis. Three years later, only 14% of depressed patients still had a clinically significant condition, had not received a diagnosis, and might have benefited from treatment2. (1) Thompson C, Ostler K, Peveler RC, Baker N, Kinmonth A-L. Dimensional perspective on the recognition of depressive symptoms in primary care. Br J Psychiatry 2001; 179:317-323. (2) Kessler D, Bennewith O, Lewis G, Sharp D. Detection of depression and anxiety in primary care: follow up study. Br Med J 2002; 325:1016-1017. Competing interests: None declared |
|||
|
|
|||
|
Michael S Small, GP Ripley, DE5 3TH
Send response to journal:
|
The myth of primary care's failure to recognise depression is trotted out yet again in this review. I am heartened to read Tony Kendrick's robust response. I would take issue with the practicality of the statement made in relation to use of prophylaxis. "A consultant psychiatrist or specialist in secondary care should evaluate the need for maintenance or prophylactic treatment." The authors recognise that 80% of patients with depression are dealt with in primary care and note the relatively common rate of recurrence. However, they fail to recognise the practical implications of making the above recommendation. Quite simply, secondary care would not have the resources to cope with the increase in referrals which would result from following such a recommendation. It is unhelpful to make such statements without considering the practical implications. Most patients at risk of recurrence are dealt with in primary care on a daily basis. I do not think our secondary care colleagues would appreciate a sudden change in referral patterns which your statement implies is necessary. Competing interests: None declared |
|||
|
|
|||
|
Hiske J. van Ravesteijn, MD and PhD student department of General Practice, Radboud University Nijmegen, PO Box 9101, 6500 HB Nijmegen, Nl, Lieke J. A. Franke, Tim C. olde Hartman, and Peter L.B.J. Lucassen
Send response to journal:
|
We appreciate the efforts of Timonen and Liukkonen (2008) to gather the evidence for the management of depression in adults and we support their encouragement to start the treatment of depressed adults with psychosocial interventions. However, we have some comments as well. 1. The evidence from published studies for the effectiveness of antidepressants is weak. There are several well performed systematic reviews to support this(1). Antidepressants’ effectiveness is even close to zero when unpublished evidence is included in the judgements(2). 2. In the light of the limited effectiveness of antidepressants, it is striking that they spend so many words on medication and so few on psychological therapies. For example, they do not even mention mindfulness based cognitive therapy, which is effective in the treatment of depression and prevents relapses(3). 3. The authors fail to distinguish between depression as a disorder and depression as a normal reaction on things happening in someone’s life. As such they adhere to the principles of DSM-IV. We consider this a major weakness as this way of thinking medicalises life difficulties. Most depressed adults, visiting the GP have self-limiting symptoms. These symptoms are often caused by ‘normal’ life difficulties. This is reflected in unwillingness of many patients to receive the ‘depression’ label for their complaints. Patients say that they are not mentally ill but have some problem. We assume that the acknowledgement of this fact, is one of the reasons why general practitioners are reluctant in diagnosing depression. Consequently, it might be more appropriate to start treatment eliciting the story of the patient and discussing this, instead of precisely diagnosing depression. Our opinion is that diagnosing depression is the next step after good listening and talking with patients. 4. Although the reviewers mention that the doctor-patient relationship is important, they state that evaluation and maintenance treatment can also be done by other primary healthcare professionals. We disagree with this, because a good doctor-patient relationship is essential in catalysing a greater self-efficacy of the patient. Another reason for disagreement is that depressive and somatic symptoms are frequently presented together. To conclude, a longer lasting doctor-patient relationship with sincere attention for the patient is essential in good management of depression. Reference List 1. Antonuccio DO, Danton WG, DeNelsky GY, Greenberg RP, Gordon JS. Raising questions about antidepressants. Psychother Psychosom 68: 3-14, 1999. 2. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 5: e45, 2008. 3. Teasdale JD, Segal ZV, Williams JM, Ridgeway VA, Soulsby JM, Lau MA. Prevention of relapse/recurrence in major depression by mindfulness- based cognitive therapy. J Consult Clin Psychol 68: 615-23, 2000. Competing interests: None declared |
|||
|
|
|||
|
Ross A. Dunne, Research Registrar, EFFECT-Dep study. St. PAtrick's Hospital, James's St., Dublin 8, Ireland, Professor Declan McLoughlin, Research Professor of Psychiatry, St. Patrick's Hospital & Trinity College Dublin.
Send response to journal:
|
Markku Timonen and Timo Liukkonen apparently aim to give a comprehensive review of the treatment of depression in adults. Their article has been published at a critical juncture for health providers as they weigh the implications of the latest meta-analysis and the imperative to treat their depressed patients. The authors have focused on psychological and pharmacological interventions, emphasising the relative frequency with which general practitioners treat depression, and this is more than reasonable. However, we are astounded at the failure to discuss the single most effective treatment for depression: ECT. The efficacy of electroconvulsive therapy is unparalleled and it has been shown to be equally efficacious in those who fail to respond to antidepressants. Its effectiveness must be weighed against side effects, most of which are short-lived. ECT is safe, cost effective, and has a response rate of 70-80%. It is also under-used and stigmatised. Its mechanism of action is being slowly charted by clinical neuroscientists, as are the mechanisms by which it causes its side effects. However, NICE guidelines specify its use for only severe depression, catatonia and treatment resistant mania. These guidelines marginalise the single most effective treatment for depression. By neglecting to discuss a major treatment for depression, the authors have missed an opportunity to raise the public and professional profile of ECT, and to challenge its stigma. Dr. Ross A. Dunne, Professor Declan McLoughlin. Competing interests: Professor McLoughlin and Dr. Dunne are currently engaged in clinical and neuroscientific research on ECT. This research is publicly funded by the HRB Ireland. |
|||
|
|
|||
|
Ricardo Gusmão, Professor of Psychiatry Faculdade de Ciencias Medicas, Universidade Nova de Lisboa
Send response to journal:
|
To reduce the gap of diagnosis and treatment of depression to an attack directed to primary care doctors is not serious, and denying twenty years of vast and consistent research all over the world, even less valid. It is even more disturbing that a PhD student, and a GP, can possibly make such an incredible confusion between the concepts of efficacy and effectiveness. Maybe someone with clinical experience could reassure him that "a longer lasting doctor-patient relationship with sincere attention for the patient is essential in good management of depression" does not make of a doctor a psychologist but just a good doctor and that in fact it increases antidepressant effectiveness, meaning, people do get better, which is, at the end of the day, all that matters. RCTs are meant to determine what they are meant to determine, and no more. Their clinical usefulness is limited. Especially when they are designed for commercial purposes such as those sent to the FDA and then meta-analysed. All this nonsense is embarrassing. Competing interests: None declared |
|||