The Truth about Depression BBC Full Documentary 2013
AWARE – Helping to defeat depression
Association for Postnatal Illness (APNI)
Ketamine: The Future of Depression Treatment?
The future
Neuroscience research is one of medicine’s new frontiers. Today’s latest scanners and neurochemistry labs tell us a wealth of information about how the brain actually works. Antidepressants work for most people but, like all drugs, they do have some sideeffects.
We can expect future generations of antidepressants to become increasingly sophisticated, more effective with fewer side-effects.
We will have more choice of medication, and a better understanding of matching the patient’s needs to the drug’s profile. The human genome project is helping us understand much more about the effect that genetics – your family history – has on the individual.
Research into talking treatments, counselling and psychotherapy is more difficult in practical terms than testing out a new drug.
We do have clear evidence that cognitive behaviour therapy and behaviour therapy are effective treatments and they are much easier to evaluate. You can’t do cognitive behaviour therapy or counselling in a test tube.
The Health Service, however, recognises the importance of providing care that is both good value and effective for people, and evidence is constantly gathered and sifted to tell us which therapy is the most effective. So stronger evidence for – and against – today’s treatments is always emerging.
The importance of research evidence also applies to alternative therapies. They too must be scrutinised for safety and costeffectiveness, just as rigorously as any other medication. St John’s wort is a good example of a herbal remedy that is a potent antidepressant – and which can interact harmfully when misused.
It may well become prescribable before long. Apart from newer drugs and the right sort of counselling, are there any different, more radical approaches to treatment?
Vagal nerve stimulation (VNS) and transcranial magnetic stimulation (TMS) are two recently invented rather remarkable methods of affecting brain function that have shown some promise in early trials for the treatment of resistant depression.
VNS involves the implantation of a pacemaker-like device in the chest wall, which is then connected to the vagal nerve in the neck. A tiny pulse of electricity is passed up this nerve into the limbic regions of the brain every 5 minutes for 30 seconds. VNS is becoming an established treatment for intractable epilepsy and is very safe. Some preliminary research has indicated that it may be an effective treatment for severe and resistant depression as well.
However a great deal more research is needed. TMS involves the application in pulses of a very strong, but much focused, magnetic field to parts of the brain. In depressive illness, the frontal regions of the brain are targeted. The TMS causes local inhibition of function (so, for example, if this is applied over the area of brain causing movement, a brief localised paralysis results). There is some published research indicating its effectiveness in depression, but more work is needed before it can be regarded as a reliable treatment. It does not seem, however, to hold out the hope of helping people with psychotic depression.
Should I take part in research programmes? My doctor has suggested that I might like to help with a trial of some new medication.
All prescribed medication has to be exhaustively tested, first in laboratories then on human volunteers. Without the people who have helped test medication, there would be no therapeutic drugs at all. So I’m in favour of all of us helping with scientific research, for the sake of each other. You will be thoroughly informed about exactly what you are taking, what possible side-effects there may be, and what benefits to expect. Your fully informed consent is necessary before you can be included in any clinical trials, and no one will expect you to take part in anything that you are not happy about.
What constitutes good scientific evidence for a treatment’s benefits?
The gold standard is a double-blind, cross-over trial, comparing an active ingredient to a placebo (an inert substance) on twogroups of carefully matched volunteer patients. ‘Double-blind’ means that neither the volunteer patient nor the doctor involved knows which people receive the active drug. ‘Cross-over’ means that the two groups of people swap treatments halfway through the trial, so that both groups have had the same intervention.
This can be quite difficult to do for some psychiatric treatments; how do you compare counselling with an inert substance, for example? How do you evaluate the effect of personal contact?
So there are many other sorts of trial, and of course talking to our patients can teach us more than anything else.
How ‘powerful’ a trial is (that is, how much importance you can attach to its findings) will depend on how many people are involved in it. If the research is looking for a fairly rare occurrence, large numbers of people may be needed in the trial and ‘control’ groups to be sure that the difference in these groups has not merely arisen by chance.
The most powerful evidence comes from ‘meta-analyses’ where the results of a number of trials (which must have identical rules) can be added together.
Aren’t there too many new drugs around for you to know the evidence about all of them?
A national body called ‘NICE’ (the National Institute for Clinical Excellence) has recently been formed to consider the evidence and form guidelines about new treatments, especially where a treatment is expensive or controversial. They publish guidelineson what is good practice.
The NHS has to be concerned not only with finding out what treatment works the best, but also with obtaining best value for money – the most cost-effective – so that our resources are not wasted on less effective treatments and so enabling more people to be treated. Most of NICE’s work so far has been on expensive new treatments where there is some controversy, such as Aricept, the new treatment for Alzheimer’s.
Bandolier is a fascinating medical journal published on the Internet, which is building up an ever increasing evidence base of good clinical trials. Currently there are more than 300 online journals participating. The Cochrane Collaboration is a group of enthusiasts who promote evidence-based medicine, and collect good quality clinical trial information.
