VIDEO
What is Depression? (Depression #1)
Choosing your treatment
How do doctors decide which treatment is the best?
We are aware of good scientific evidence that treatments are effective and safe. This is by far the strongest and most objective reason, and we try increasingly nowadays to base medical treatment on published evidence. There are many medical journals and publications, and scientific papers have to be rigorously scrutinised by referees to check the ethics, logic and the statistics, before a paper can be approved for publication. A multitude of research papers worldwide fail to get published if they cannot meet the referees’ standards.
If a paper is published, it means that clinical trials on large enough numbers of people have shown measurable benefits, but the most powerful evidence comes from ‘meta-analysis’, that is where all the known trials of a drug or treatment are put together mathematically. That way, relatively small effects and rare sideeffects can be observed, as the largest numbers of people are involved.
Choosing the correct treatment in psychiatry can be difficult.
There are a variety of approaches and drugs available, but no really clear pointers to which precise approach, or drug, will work in an individual. Good treatment in psychiatry takes account of the whole person, the personality, the circumstances and what view he or she has on life.
We are increasingly encouraged to use ‘evidence-based’ medicine in all areas of medicine – not just psychiatry. This involves using treatments that we know to work and have been shown to work in research. Good and sound though this approach is, there are limitations:
• In psychiatry we are often dealing with people over 65 years of age and relatively little research addresses them specifically.
• The ‘best’ treatment according to research may not be a practical or acceptable treatment to the person with depression.
A person, for very good reasons, may not be prepared to take a tablet, but may accept a syrup (there is not always a choice).
Electrical treatment may be the treatment of choice in some severe depressive illnesses. Some people will not accept this and alternatives (possibly less effective) have to be found. We know that cognitive behaviour therapy is very helpful in the treatment of depression. Sadly this may not be available either in general practice, or within the hospital setting, without a long wait.
Evidence-based psychiatry is not nearly as clear-cut as, for example, the treatment of high blood pressure, where the person usually has less firmly held views on the choice of treatment.
Negotiation of a treatment that is acceptable and helpful to the person is terribly important. Ultimately we still have to rely on our experience and acumen to make many judgements and decisions where there simply is not as yet cast-iron evidence.
How can I judge how my treatment is helping?
At first you are unlikely to notice a great deal. After a few days on antidepressants you may realise that your sleep is better in quality. Your moods may then become less labile; that means fewer variables. Irritability is reduced and, as your battery gradually recharges, you will find that you have more mental energy in reserve, and that you can cope better with life.
Antidepressants are not stimulants or happy pills, so you don’t start to feel happy, but your mood will gradually lift. This can take time. Don’t give up too soon. A proper trial of medication may take as long as 2 months. If there is no change after this time, your doctor is likely to need to review things and reconsider your treatment.
As time goes by, taking an interest in your usual activities, hobbies, sports or pastimes will also help. You get stimulation and enjoyment from pleasurable activity again (that’s why we call it‘re-creation’).
What books do doctors rely on for information about drugs?
We’re all sent regular copies of the British National Formulary (the BNF). This contains information about every licensed drug in the United Kingdom. It is updated quarterly, and has information about drug costs, side-effects, and interactions. It disparages less effective remedies. It gives a thumbnail sketch of each licensed drug. Besides giving details of all medications used for depression, anxiety and other psychiatric conditions, it has good sections on prescribing in pregnancy, breastfeeding and childhood.
We are also sent a smaller monthly booklet called the Monthly Index of Medical Specialities (MIMS). If your doctor wants to check the dose of a drug, you will probably have seen the doctor using one of these two booklets. Many of us now have all this information on our computer screens.
My doctor has referred me to a psychiatrist. What will happen?
General practitioners refer only about 5% of people who are depressed to a specialist. Most people with depressive illness will be treated successfully and respond to treatment set up by their doctor. If you are referred for an outpatient appointment, there is a high chance that you will need to attend only for a limited period. Two-thirds of people referred to psychiatric outpatient clinics will be helped in about four sessions.
