Fábio Gomes de Matos e Souza, Professor of Psychiatry at the Federal University of Ceará, Brazil, discusses the challenges and progress experienced in many years of treating major depressive disorder (MDD).
Each year, Professor Souza’s group sees around a hundred patients with a first episode of depression and cares for a total of 200-250 MDD patients, primarily in an outpatient setting.
What are the most significant challenges facing clinicians treating MDD?
The first is diagnosis. The depression may be unipolar or bipolar, and possibly mixed with other comorbidities such as anxiety and substance use disorder.
The second is education. Patients ask “When will I be cured?” They have to understand that depression may be a chronic disorder. Adherence is fundamental, but the context is that we have agents that are effective, and well tolerated. Families also have to be educated about the need for long-term treatment. And both patients and families need to understand that there may be biological and genetic vulnerabilities.
In severe cases, there may also be risk of suicide. This has to be sensitively approached and managed.
Then come the challenges of treatment.
What is the best approach, and what can be achieved?
We work in a university setting, so we have a team of psychiatrists, psychologists and social workers and can incorporate interdisciplinary working into clinical practice. Medication alone is not enough. Patients may have to modify lifestyle factors such as excessive alcohol and poor patterns of sleep. They need to develop the skills needed to manage conflicts within the family, and to negotiate the workplace: some employers are not understanding when it comes to depression.
So there is also usually cognitive behavioural therapy (CBT). This technique is more research-based than other psychological approaches, and patients tend to respond well and more quickly. They understand the dynamics of it, and you don’t have to pull out early childhood. Given the huge demand, we need treatments that make people feel better as quickly as possible: there is no time for long psychotherapies, even if they work.
What are the most significant advances you have seen?
We now have drugs with fewer adverse effects, less risk of drug interactions, and a lower risk of inducing obesity. We have different drugs that can be suitable for different patients. But the therapeutic challenge is that around 30% of patients don’t respond well to the medications usually prescribed. So, despite significant advances in our understanding of depression, there is still a large group whose need for adequate treatment is not met.
We don’t want just a reduction in symptoms – we want them to return to good functional roles
What proportion of your patients experience remission, and how do you define it?
For many years, the focus was on response not remission. But a 50% reduction on the MADRS or Hamilton scales is not sufficient. We don’t want just a reduction in symptoms – we want patients to be able to return to good functional roles in study and work and emotional life, and to have restored joie de vivre.
So, while perhaps 50% of patients have control of symptoms, maybe only a third achieve remission in this sense.
One reason is that we have not focused sufficiently on cognition. Deficits in memory, attention and executive function can be disabling. Concern with enhancing these areas may improve chances of full remission.
Another is that you lose neurones with each depressive episode. And to achieve remission you need an intact brain. So every effort should be made to avoid the next episode. This means treating not just the episode but the disease. If depression is treated properly, the chances of a next episode can be reduced.
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