Depression (also called depressive illness or clinical depression) is a common condition, affecting up to 20% of the adult population in their life times. Many go untreated. Of those that do seek help, the GP is usually the first port of call. He or she will assess the severity of the symptoms and recommend the appropriate course of treatment.

Depression is commonly ranked in terms of severity – mild, moderate or severe. Severe cases are relatively rare and will usually be referred on to the local psychiatric teams. Mild and moderate cases common and will normally be treated by the GP, at least initially. Failure to improve in these cases may precipitate referral to specialist care for advice and treatment.

The treatments available for mild and moderate cases of depression fall into two main categories – drug treatments and "talking" treatments. GP's commonly prescribe medications in the first instance. The reasons for this will be discussed towards the end of this article.

Antidepressant medications were first discovered (by chance) in the 1950's and 60's. Medications designed to be used for very different (physical) conditions were found to be effective in depressed patients. These first antidepressants, such as Amitryptilene and Imipramine, are called the Tri-Cyclic Antidepressants or TCAs (named after their chemical structure). Trials have shown them to be about 70% effective in relieving the symptoms of depression. The effect is not immediate, typically taking 4 to 6 weeks. This effectiveness is to be compared to the placebo tablets used in the trials. Placebos are non-active tablets given to patients to correct for the positive "psychological" effect of taking any tablet, whether the tablet is effective or not. The placebos (e.g. a sugar coated pill) are typically effective in 50% of cases! It is also worth noting that observation studies of depressed people show that around half improve "spontaneously" (i.e. without any treatment at all) after a short period.

So the TCAs are more effective than placebo's. If you gave a TCA to ten depressed people, around seven would be improved after six weeks; giving a sugar pill to the same number, around five will be improved after the same time period.
Unfortunately, TCAs have significant side effects. Patients commonly feel sedated, put on weight, suffer dry mouth and constipation, and have slowed reflexes. Importantly, TCAs are very dangerous in overdose – a significant consideration in those patients who feel suicidal.

Over the ensuing decades, pharmaceutical companies in the area of antidepressants have conducted much research, and many new drugs have appeared on the market. The main focus has been on producing "cleaner" drugs, drugs that are effective but do not possess all the side effects of the TCAs. This has largely been a success. The newer drugs, such as the Selective Serotonin Reuptake Inhibitors (SSRIs) e.g. fluoxetine (Prozac), do indeed have less side effects. This appears due to their method of action – SSRIs effect only 1 or 2 of the brains neurotransmitters, the older drugs can affect 3 or 4. And they seem to be as effective as the TCAs – but they are not more effective. It is one of these newer antidepressants that GP's typically prescribe for their patients. These drugs are amongst the most widely prescribed medications in the West.

But what of those who don't improve – the 30% who don't get better? Or those who suffer severe side effects? The GP may change the dose of the drug, or switch to an alternative drug, or refer the patient on to the psychiatric services. Other patients may not want to take medications for their psychological or emotional difficulties at all.

This group of patients would seem well served by the "talking therapies" such as counselling, psychotherapy, CBT and NLP. In mild and moderate cases of depression they seem at least as effective as antidepressants, and without the side effects. Further, through these therapies, patients are encouraged to examine their problems and difficulties in detail, allowing them to actively participate in their resolution rather than simply taking a tablet every day. Ideally this leads to the patient acquiring strategies and ways of coping with difficulties in their lives that will enable them to not only resolve these difficulties in the present but also prevent their re - occurrence in the future. Effective talking therapies have the potential to remove patients from recurrent cycles of depression. The drug treatments are effective for only as long as they are taken – potentially a lifetime.

Given that talking therapies are an effective treatment for depression and their lack of unpleasant side effects, why aren't they offered more often by the GP? A big consideration here is cost – antidepressants are undoubtedly cheaper than employing a therapist. Secondly, it is quicker and easier for the GP to write a prescription for an antidepressant than it is to think and consider which therapy may best help the patient. Finally, there is huge economic interest in the prescribing of these medications. Pharmaceutical companies make huge sums of money from these drugs. They spend a considerable sum (more than they actually spend on researching and developing the drugs!) on advertising and promoting their particular brands to the medical profession. The GP is under both time and economic constraint, and a tablet billed as a "wonder cure" can be very appealing.

None of this is the fault of the GP. The NHS has well publicised money problems, and decisions about which treatments are cost-effective are constantly being made (the pharmaceutical industry lobbies these decision makers also). The result is the situation as it stands – drugs are prescribed, other therapies aren't. This isn't a situation exclusive to mental health – back pain and other injuries are typically treated with painkillers, when physiotherapy or a similar treatment may well be better for the patient.

Talking treatments for depression are generally not available on the NHS or, if they are, there is likely to be a lengthy waiting list. This is a result of economic decisions, not a shortage of trained practitioners. One has only to look in the phone book to see numerous highly qualified and experienced therapists ready to help. Unfortunately, the NHS's priorities lie elsewhere.

Autor: Treatmentfordepression

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