Depressed patients need more than drugs and psychiatrists
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7384.338 (Published 08 February 2003) Cite this as: BMJ 2003;326:338
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests