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Contemporary Management of Depressive and Anxiety Disorders

David Bakish, MD, FRCPC
Associate Professor of Psychiatry, University of Ottawa
Head, Psychopharmacology Unit, Institute of Mental Health Research
Royal Ottawa Hospital

 
q Do you have a sense that the medical profession's attitude toward mental illness has evolved over the past little while? If that has happened, what has prompted the change in thinking?

a Over the past ten years, there has been a dramatic shift in the attitude towards mental illness. It's very clear that the biological parameters are becoming more important. It's very good for psychiatry because it's bringing it much closer to medicine in general.
   
q Was it the modern antidepressants that became available that allowed us to look at mental illness as more of a biological issue and less of a moral issue?

a Really it was the anti-psychotics that started it, where you had patients who had very severe illnesses such as schizophrenia and manic-depressive illness who were able to be treated properly and had benefits from biological treatment and then as we got antidepressants that became more user friendly, that trend just continued.
   
q In what way have the newer and presumably better tolerated antidepressants contributed to an improved management of depression and anxiety?

a What has happened is that we have much better compliance with the newer antidepressants. The previous generation, which were basically the old monoamine oxidase inhibitors and the tricyclics, were very effective agents but in the long term, the patients' biggest question was when they could get off of them so they wouldn't have to have the side effects. The newer generation starting with the SSRIs really made long term treatment much more tolerable to the patients and we have better compliance.
   
q There still have been relatively recent reports that as much as 85% of depression goes undiagnosed. Are we doing better today, or is depression still often overlooked?

a In my personal opinion, most of the depression, as you have stated, really goes undiagnosed. We're starting to do a little better in the last two years. There was a recent study done in the States, which showed that at the most, 30% of the population who had depression was diagnosed, and of that, only half ever got adequate treatment.
   
q Is there a reason as to why perhaps depression is so under-diagnosed and obviously under-treated?

a Well, the simple reason is that there's no obvious biological test, because if we had one of those then it would be relatively easy to diagnose. The diagnosis is a clinical diagnosis and unfortunately, it gets mixed up with depression. You have two ways of looking at depression. One is in the diagnostic category, such as an illness, but the other is that people say they're depressed when they're sad, when they have events that affect their lives. There's a difference between depression as an illness and depressed mood as a symptom.
   
q Do you think it might be helpful if physicians might have had a major depression themselves, and they may well be able to appreciate better what it's like to be depressed?

a I have no doubt whether it would be helpful. Whether it's necessary I'm not so sure.
   
q It's been said and reported that a significant proportion of anxious patients are also depressed and vice versa. How do you tease out which is the primary disorder and why is it important to do so?

a There is a great deal of comorbidity between depression and anxiety. This is something that was always very difficult to do and at present, with the newer antidepressants that treat anxiety as well as depression, you are able to kill two birds with one stone. It was a very important thing to do, when, if the patient was depressed, you were going to give antidepressants, but if he was anxious, you were going to give a benzodiazepine. In that case, you had to make sure that you eliminated depression, not to inappropriately treat depressed people with a benzodiazepine. The benzodiazepines would have treated the anxiety symptoms, but they would not have treated the depressed symptoms and that probably led to a lot of long-term benzodiazepine users who needed to stay on something because their basic depression wasn't treated.
   
q What goes into your decision personally, to use, say, one SSRI over another or perhaps one of the newer cyclic agents?

a Probably what goes in is whether a patient had a response to the SSRI in the past or whether somebody in the family had a response. That would be one of my first choices. With one of the newer cyclic agents, if they have not had any response to an older agent, perhaps I would use one of the newer cyclic agents. But since the newer cyclic agents are as efficacious, if not more efficacious than the SSRIs, I would try them anyway.
   
q If you have a patient, for example, who has had his/her first episode of depression, would you gravitate towards the newer cyclic agents, given that they are reported to have a better side effect profile?

a That depends if they had a response. If they had a complete response, and let's say it was their first or second episode, and they went off and then had a relapse a few years later, I would treat them with the same antidepressants that got them well.
   
q What about patients who are reluctant to take antidepressant medication? Often they may be reluctant to take any medication, period. How do you convince them that treatment is likely to help?
a I don't try and convince them. I just try to educate them. As long as they have some contact with reality, they have to make the decision. I use the process of education.
   
q What elements go into that educational process?
a Well, an explanation of the natural history of the illness, and also a very good analysis to see how many episodes they've had in the past, where, if they've only had one episode or two episodes, this episode may resolve as well. But for sure if they've had three or more episodes, the present episode isn't going to resolve without any antidepressant treatment. Then I would be more forceful in really telling them antidepressants are what they need.
   
q Before you start a patient on whatever therapy, what kind of information do you feel is really vital to give patients before they start?

a I think what's very vital is first to tell them that the antidepressant treatment takes a certain amount of time to get going, that some mild side effects usually do occur at the beginning until you adapt to the antidepressant and also that it's important to realize that 70% of the patients will respond to the first antidepressant that you do give them.
   
q Do you consider adjunctive therapy, perhaps cognitive behavioural therapy or other types of therapy in certain categories of patients?

a There is no doubt that a cognitive behavioural approach is very useful in patients who have what we call negative skew. That means that they've been depressed for long enough that they look at things from a negative perspective. These patients probably not only need the antidepressant, but they do need some cognitive therapy to help them "see the light".
   
q And are there situations in which you would recommend electroconvulsive therapy over medications?

a Electroconvulsive therapy probably would be the first-line choice in psychotic depressions or delusional depressions, because these patients are really suffering a lot and we know that it takes three to four weeks for antidepressants to work. We know that with electroconvulsive therapy, we would get them better in about two weeks and that is a major advantage for them. In the other types of depression, as electroconvulsive therapy really does not last for long (it may work for two to three months), they would have to be on an antidepressant anyway, so if you do not need to do it right away you might as well start them on the antidepressant and see if they respond to that.
   
q Once patients do get well, how do you convince them to stay on medication even though they're no longer depressed?

a That's one of the great tricks of the trade, I think. The first thing is that you have to do a really complete history and see how many previous episodes they've had. Because that is the determining factor as to whether they would need what we call long-term maintenance treatment. If somebody is in their first episode, you could treat them for a year, and then it would be absolutely appropriate to tell them to go off and wait to see if it comes back again. 50% of the patients will never have another depressive episode, while the other 50% will go on to recurrent depression. However, if they've had three episodes in the past that are documented, their chance then of having a relapse is over 90% and then, I explain to the patient, that they would probably be better off in staying on their antidepressant, especially if they had such serious depressions that they were either psychotic or suicidal.
   
q What do you like about practicing psychiatry?
a What I like about psychiatry is that, out of all the medical specialties, this is one of the specialties where we have the highest success rates, you really see the benefit for the patients, and we may not cure it, but we can definitely treat it.
   


Over one million Canadians suffer from some form of depressive illness.