Is it Time to Revise Our Understanding and Management of Depression?

Can J Psychiatry 2008;53(7):409-410 Each of the 2 provocative papers in this In Review challenges us to rethink our understanding of and approach toward depression. Dr Scott Patten,1 one of Canada's preeminent psychiatric epidemiologists, presents powerful new evidence that refutes prevailing wisdom about depressive illness. Dr Gavin Andrews,2 a prominent psychiatrist-researcher at the University of New South Wales, Australia, leads us through a series of provocative questions that demand reconsideration of existing approaches to depression treatment. Are we up to the challenge? To revise our beliefs about a condition as prominent as depression is not a simple task. It is well established that, as health care practitioners, we have a tendency to cling firmly to medical knowledge learned earlier in our careers and we often resist changes in practice.3-5 Surgeons must repeatedly abandon outmoded operative techniques and master new surgical approaches if they are to provide their patients with the most effective treatment available. In psychiatry, we too must revise our approaches in response to the emergence of new knowledge. Possibly, revision of pharmacotherapeutic practice is relatively less challenging in this regard. We are accustomed to the continuing development and release of new drugs for the treatment of depression and we are familiar with shifts from one generation of drugs to the next that sweep through professional practice, heralded by reports of clinical trial findings and accompanied by extensive advertising and marketing efforts by the pharmaceutical industry. Nonetheless, we have learned that such sea changes in pharmacotherapy are often choppy. After riding on a wave of initial fanfare and optimistic proclamations about the potential superiority of new-generation medications, once in widespread use, some will be found to have disappointing results or will be accompanied by unforeseen dangers and, ultimately, will sink. Other new medications will be found to provide true benefits over previous agents. To be able to discern risks, costs, and benefits well, we will need to ensure that high-quality, unbiased research is conducted, interpreted properly, disseminated, and used widely. In Canada, we are lacking adequate mechanisms for timely knowledge exchange that mental health practitioners and consumers can rely on to be credible and sound. One of the goals of the new Mental Health Commission of Canada is to address this gap in knowledge exchange,6 thus we can be optimistic that appropriate mechanisms may become more available. Possibly, it is more of a challenge to incorporate and use new knowledge about psychosocial interventions and treatments. An example of this may be identified by tracing the emergence of cognitive behavioural therapy (CBT) and interpersonal therapy (IPT) for depression. Following their introduction in the 1980s, CBT and IPT were demonstrated to be effective and safe interventions for most people with depression. Nonetheless, many Canadian mental health service providers treating people with depression did not incorporate CBT or IPT into their armamentaria, and evidence-based psychosocial treatment for depression remains largely inaccessible. In Dr Andrews' paper,2 we are provided with some strategies that may result in wider dissemination of evidence-based psychosocial treatments. However, these will require changes in the way services for depression are delivered. Given the substantial disability and suffering that results from depressive disorders, and considering that most clinical guidelines recommend that CBT and IPT be made available as important treatment options, it is surprising that we do not find more health care practitioners in Canada taking up these treatments. There may be various factors contributing to the lacklustre uptake of CBT and IPT for depression in Canadian health care services. Nevertheless, one must consider whether this constitutes, at least in part, an indication of the resistance to change in practice that I have suggested. …

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