June 17, 2003 — Although a record number of Americans with major depression are now getting treatment, most treatment is still inadequate, say Harvard researchers.

Major depression treatment was more often inadequate from primary care doctors, according to their new study. Patients being treated by primary care doctors more often took the wrong type or dose of antidepressant, failed to take the right drugs for long enough, or sought unproven treatment from those outside established medical circles.

These findings are among several detailed in this week’s Journal of the American Medical Association, courtesy of a survey of more than 9,000 Americans and the first of its kind in more than a decade. Among the other findings:

• Most people with depression have moderate to severe forms of major depression. Only 10% of depressed Americans have mild, fleeting episodes that may not require treatment. Some 13% of people with major depression require immediate hospitalization.
• The typical American with major depression is unable to work or perform everyday activities for 35 days each year. Those with the most severe major depression typically lose some 90 days each year.
• About one in six American adults will have major depression sometime in their life, and nearly 7% of adults — almost 14 million people — will have major depression that warrants treatment in any given year.

Depression With a Capital D

“When we say that 13 to 14 million Americans are depressed a year, we’re talking about depression with a capital D,” says study lead researcher Ronald Kessler, PhD, of Harvard Medical School. He tells WebMD that only one in five patients with major depression are getting adequate care.

The problem, he says, often stems from the fact that many depressed people are treated, at least initially and sometimes exclusively, by their primary care doctors or others who don’t specialize in treating major depression.

“The good news is that effective treatments exist, and your best chance of getting it is to go to a specialist, a psychiatrist, or other mental health specialist. With good treatment, the success rate is pretty high,” Kessler tells WebMD.

“But many patients are treated by their family doctors and get the wrong medications — for instance, Valium instead of antidepressants. They’re also getting the wrong dosages, because physicians unfamiliar with treatment guidelines tend to be conservative in dosing. And patients are just not getting treatment for long enough, often because they discontinue medication because of side effects and not seeing results.”

Most of those reporting major depression in the previous year say they had received treatment — up from about 30% a decade ago. But Kessler found in four of five patients, that treatment doesn’t meet minimal standards, which recommend a two-week follow-up after the initial office visit in which medication is prescribed, and three other appointments to monitor the drug’s effectiveness.

Thoughts From a Family Physician

“If family doctors are prescribing the wrong medication and dosages, we need to know that. But that would be rather surprising to me, since once a diagnosis is made, the treatment is pretty straightforward for the majority of patients — usually SSRI antidepressant medications,” says Sharon Sweede, MD, spokeswoman for the American Academy of Family Physicians.

“A lack of four follow-up visits just to manage their depression medicine would not be surprising at all, because family docs see people for a variety of reasons, and often do multiple things in a single visit. It may not be perceived as they are there just to manage a patient’s depression.”

What About Psychotherapy?

The recommended treatment guidelines for major depression also call for at least eight psychotherapy or counseling sessions, each lasting a minimum of 20 minutes. Kessler’s study didn’t specifically look at psychotherapy treatments patterns. But another expert not involved in the study says that the ongoing stigma that’s associated with major depression may prevent many patients from getting the right treatment combination of both medication and counseling.

Many Suffer in Silence

“In our culture, having major depression translates to a perceived weakness, and what that amounts to is a lot of people who are depressed privately and suffer in silence,” says Stephen Schlesinger, PhD, of Northwestern University’s Feinberg School of Medicine and a spokesman for the American Psychological Association. “There is no question that treatment is best when therapy and medication are used together and doesn’t involve just medication. If I have depression, I know how I feel. I would want to figure out why and determine what makes me tick.”

Bob Carolla, spokesman for the National Alliance for the Mentally Ill, a nonprofit advocacy group, says that Kessler’s finding helps validate what mental health specialists have long known — that major depression is a serious, debilitating illness.

“You’re not talking about a character flaw or laziness with major depression. You’re talking someone who is so paralyzed that they may have trouble being [made] to make breakfast and get into car and drive to work.”