Other approaches to depression

In my last post I mentioned that prescribed medication isn't the only recognised approach to managing depression. Although it would be an impossible task to describe or even list all the different approaches to treatment that have been tried for this problem, perhaps readers would find it helpful and/or interesting to hear about the ones that I, Mr Average GP, would most often consider for my patients.

Startlingly, one of the treatments that the UK's NICE guidelines suggest for depression is Nothing At All. To simply see the patient again for reassessment after an interval of two weeks is, at least in the minds of NICE's experts, a perfectly acceptable option, provided that he or she has a reasonable chance of improvement without intervention. This is counterintuitive to most doctors - by and large we incurably driven to intervene in our patient's lives, it makes us feel that our existence and remuneration are justified - but it's still helpful advice.  It highlights that not every patient who gets depressed wants a solution from outside, and also that depression will very often improve spontaneously in a short time.

Another recommendation from NICE is an exercise programme, with a suggested regimen of three sessions per week for two to three months. Doubtless visitors to this site will be in favour this approach, and I myself would tend to agree, although with a couple of provisos; firstly that the evidence from trials on this is frankly inconclusive and secondly that in doctors' experience one of the last things that a typical depression-sufferer will be inclined to undertake is the discipline of regular exercise. In a similar vein, NICE advocates encouraging depressed patients to find their own self-help solutions, with the provision of appropriate written resources. It's another approach that makes good sense although without supporting clinical evidence.

One treatment is noticeable by its absence from NICE guidance even though the available evidence appears to be in its favour. No prizes, I am referring to Hypericum perforatum, also known as St John's Wort, a remedy that has silenced those who would seek to dismiss all herbal therapies as quackery by showing the same efficacy in trials as popularly-prescribed antidepressants.

The only excuse that I can think of for NICE's failure to suggest its use is its unhelpful tendency to interact with a range of commonly-prescribed drugs (for example hormonal contraceptives), although this is an issue on which any self-respecting doctor or pharmacist should be perfectly able to guide patients. I fairly often recommend over-the-counter hypericum to patients, particularly those who, for various reasons, do not wish to take prescribed medication for their depressive symptoms. As with drugs such as SSRIs, its pharmacological activity may be modest, but when compounded by a sizeable placebo effect the difference can be substantial.

And what about psychological interventions? Here NICE and the available evidence are in agreement: there are several kinds that work, including Cognitive Behavioural Therapy and interpersonal psychotherapy. The great challenge for GPs is accessing these therapies - the waiting times in most regions are reminiscent of the bad old days of the NHS, mainly due to a lack of suitably qualified therapists working in the public sector.

An interesting solution to this problem, and one whose cost-effectiveness has clearly endeared it to NICE, is interactive computerised C.B.T., a tempting option for GPs whose patients are in need of prompt psychological intervention and do not object to this being delivered by a fantastically clever machine instead of a fellow human being.

Of course many complementary therapists offer treatment for depressed patients. For me, as outlined in a previous blog, the lack of supporting clinical evidence is a barrier to my making actual recommendations where most complementary treatments are concerned.  Still, exponents of yoga can cite some favourable trial data. When it comes to acupuncture, however,  there is a disappointing lack of such data (in contrast to the growing evidence for its effectiveness in a range of physical conditions).

Lastly I should mention the Therapeutic Alliance, a phenomenon akin to both the placebo effect and the benefits of supportive counselling. The term refers to the healing potential that lies in the interaction between a patient in search of help and a professional in whom he or she has some degree of confidence, and who shows a genuine willingness to engage and to offer that help. In my experience, this healing potential is highest when there are several meetings.

So, in conclusion, if you believe that you may be suffering from depression, please don't let a healthy scepticism of antidepressant drugs prevent you from finding out what you and your doctor might be able to do about it.