Q: What are the most significant challenges facing clinicians treating major depression?

A: I work in outpatients but at the severe end of the spectrum -- at the moment in the UK but before that in Sweden. The biggest problem is understaffing. We don’t get to follow patients up frequently enough, including when we change their medication.

Waiting times are so long that -- by the time patients get to see a specialist – many are so unwell that the first-line treatments are not going to work. Some already have treatment-resistant depression and negative patterns of thought that are so ingrained they are difficult to change. So you have to be creative. Perhaps we should have a forum where we can access innovative approaches. 

A lot of these problems could be prevented. But resource issues make it difficult to give patients the care you want and the care they require.

Q: So what is the best approach?

A: Communication between patient and therapist makes a huge difference. If you give hope and “market” your treatment concept in a positive way, patients will give it a try. But the approach to treatment has to be individualised. I follow evidence-based guidelines but I am a great believer in “horses for courses”. Tailoring treatment to particular circumstances can make a huge difference to the potential for recovery.

That applies to drugs and it applies to psychotherapies. Psychoanalytic psychotherapy is out of favour but has a place. The effects of cognitive behaviour therapy are more easily measurable in specific illnesses, but many of our patients do not have “pure” depression. There may be concurrent personality disorder, for example, or eating problems. Things are never that simple!

A big issue in depression is patients feeling responsible for their mental health. Many don’t like the idea of pills. My approach is the smallest number of medicines and at the lowest dose needed for someone to feel well. That may mean no drugs, or it may mean the heavy artillery. It depends on circumstances. Patients may not like the idea of polypharmacy, but even that is negotiable, at least for a while.   

Q: And what can be achieved?

A: In my experience, even with severely ill outpatients, we can achieve a decent improvement in half those we see. This is by using a combination of psychopharmacology and psychotherapy: whatever it takes.