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Table of Contents
Year : 2019  |  Volume : 33  |  Issue : 3  |  Page : 122-124

Unmet needs for the management of depression

Department of Psychiatry, Far Eastern Memorial Hospital, New Taipei City; Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan

Date of Submission12-Jul-2019
Date of Acceptance15-Jul-2019
Date of Web Publication30-Sep-2019

Correspondence Address:
Yi-Ju Pan
No. 21, Section 2, Nanya South Road, Banciao District, New Taipei City 220
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TPSY.TPSY_25_19

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How to cite this article:
Pan YJ. Unmet needs for the management of depression. Taiwan J Psychiatry 2019;33:122-4

How to cite this URL:
Pan YJ. Unmet needs for the management of depression. Taiwan J Psychiatry [serial online] 2019 [cited 2023 Mar 25];33:122-4. Available from: http://www.e-tjp.org/text.asp?2019/33/3/122/268313

Depression is the largest cause of disability worldwide. According to a report by the World Health Organization (www.who.int/mental_health/management/depression/en/), more than 300 million people are living with depression globally, an increase of more than 18% between 2005 and 2015. Although there are known treatments for depression, fewer than 10% of those affected receive such treatments in many countries, probably owing to barriers including lack of resources, lack of trained healthcare providers, and social stigma (www.who.int/en/news-room/fact-sheets/detail/depression).

  A Lack of Culturally Adapted Diagnostic Criteria Leading to Greater Difficulty Top

In Taiwan, key challenges emerge for both the identification and treatment of patients with depression. The prevalence of depression is known to vary across different cultures. In the 1980s, the lifetime prevalence of major depressive disorder (MDD) as determined by the Diagnostic Interview Schedule was ranged from 1.1% in Taiwan to 19% in Beirut [1],[2]. A more recent survey conducted between 2003 and 2005, the Taiwan Psychiatric Morbidity Survey (TPMS) [3], reported a 1.2% lifetime prevalence for MDD using a face-to-face interview (with the paper version of the World Mental Health Survey of the WHO Composite International Diagnostic Interview). Research based on claims data from the National Health Insurance Research Database (NHIRD) estimated that the one-year prevalence of treated depressive disorders is around 1% in Taiwan [4].

In contrast to the optimistic interpretation of lesser disease burden, such a low prevalence of depression in Taiwan likely suggests greater difficulty in identifying patients in need using the currently available diagnostic criteria. One school of thought concerns that the diagnostic threshold of MDD may be higher as people in non-Western countries may not show positive responses to individual symptoms of MDD as often as Westerners do and the administration of identical diagnostic measures may identify different levels of depression across cultures [5]. Indeed, people with MDD in Taiwan have been found to have more lost workdays, ranging from 5.8 days for no impairment to mild impairment to 61.3 days for those with severe impairment, while their counterparts in the US have 2.1 and 53.5 days, respectively [3]. In a similar vein, Koreans diagnosed with MDD also have shown more work impairment in their nationally representative sample [6]. Although lost workdays can be influenced by labor market conditions, the finding implies that the severity of symptom and associated functional impairment may be greater in those Asian patients with MDD diagnosed using the same diagnostic measures.

Cultural stoicism has been used to explain the lower prevalence of MDD in the Taiwanese population [7]. When a Western-designed structured diagnostic interview is applied to people who tend to repress their feelings, the culturally determined “response bias” may lead to a lower estimate of the prevalence of emotional problems. This stoicism may be reflected in the much lower percentage of help-seeking behaviors: only 20% of adults with MDD in the nationally representative sample of TPMS in Taiwan sought any kind of help in the previous year [3], compared to 57.3% in the US [8]. In addition, 68.9% of individuals with MDD in TPMS have reported low perceived need as the reason for not seeking professional help compared to the figure of 25.9% reported in the US National Comorbidity Survey Replication [9]. The phenomenon of low perceived need, low help-seeking behavior, and low prevalence of diagnosed MDD which suggests the need of more culturally adapted diagnostic criteria, have been found not only in Taiwan but also in China, Korea, and Japan [6, 10, 11]. Those findings suggest a multifaceted challenge in identifying and managing MDD patients for policymakers, healthcare providers, and society.

  Obstacles to Achieve Remission and to Restore Functioning in the Real World Top

Over the past decades, responding to depression treatment but not achieving full remission has become increasingly recognized to cause an adverse outcome [12]. The consequences of not achieving remission can be serious, leading to greater risk of relapse/recurrence [13], more frequent depressive episodes, shorter periods between episodes [13], and even increased morbidity and mortality [14],[15]. In contrast, treating to remission is shown to be beneficial to long-term outcomes, leading to a reduced risk of relapse and improved psychosocial functioning. But to achieve remission is never easy in the real world.

Following initial monotherapy for MDD in the STAR*D study, only about 30% of patients achieve remission, indicating that 70% of them experience residual symptoms [16]. Besides, remission is increasingly difficult to achieve after each treatment failure, and an estimated one-third of patients do not achieve remission even after four optimized, well-delivered treatments [17],[18]. Based on Taiwan's NHIRD, one study with a national cohort of patients receiving at least one antidepressant prescription for treatment of MDD or other depressive disorders sheds light on the real-world experiences of depression treatment in routine practice [4]. Among the 216,557 adult individuals with depressive disorders, only 58.4% have at least three antidepressant prescriptions in the first three months of initial encounter; 13.7% drop out of treatment early but return later over the 18-month observation period; another 27.9% drop out early and never come back [4]. By adopting a database definition of remission – “sustained treatment-free status,” another Taiwanese study revealed that among adult depressed patients having at least three antidepressant prescriptions within the first three months, 34.1% have achieved remission status while 56.6% are continuously on antidepressant treatment; another 9.4% have cessation of antidepressants for six months, but relapses/recurrences occur later which have urged contacts to healthcare services again during the 18-month observation period [19]. Despite careful advice that even the remitted depressed patients should be maintained with the same dosage of antidepressants as used in acute treatment at least for 6–9 months [20], the reality is that nearly one-half of depressed patients drop out from our clinic within three months, and a substantial portion of them never comes back. Among those who have at least three antidepressant prescriptions within the first three months, only around one-third have achieved some level of symptomatic remission after the initial antidepressant treatment.

Furthermore, the lack of synchronicity between symptomatic and functional improvement highlights another unmet need. A survey conducted on patients with 12-month MDD showed that 97% of patients have reported some level of functional impairment and 60% severe or very severe functional impairment [8]. While healthcare providers still set a goal of treating depressive symptoms to remission, depressed patients report positive mental health, return to usual, normal self, and return to usual level of functioning at work, home, or school as key factors [21]. Unfortunately, functional impairment may persist for long after depressive symptoms remit. A systematic review has estimated that functional remission rates vary from about 20%–40% across studies and for every 10–15 treated patients, only one patient will achieve functional remission [22].

Across the longitudinal disease courses, noticeable differences exist between the reported perceptions of patients with MDD and healthcare providers regarding symptom, functionality and treatment priority [23]. Patients report more frequently mood, physical, and cognitive symptoms and greater impact on psychosocial functioning than healthcare providers in the postacute and remission phases. They also give high emphasis on addressing psychosocial functioning impairment early in the disease course. In the postacute and remission phases, a greater percentage of patients report severe difficulties in domains such as autonomy, cognitive functioning, financial issues, interpersonal relationships, and leisure time [23]. The discrepancy between the perceptions between depressed patients and healthcare providers underscores the critical need to establish clinically meaningful assessments and goals for functionality and to determine predictors of functional response in subgroups of depressed patients based on symptomatic phenotype and functional impairment which may not be identical as those predictors of symptomatic remission.

  Time to Look Into the Nature of Treatment-Resistant Depression? Top

One of the most worrying issues of depression management nowadays may be treatment-resistant depression (TRD). Despite ongoing debate over the definition of TRD, most researchers define TRD as nonresponse to two adequate courses of treatment [24],[25],[26]. To take a thorough history is important when dealing with a patient with TRD to identify comorbid physical and mental disorders as well as to reduce the rate of misdiagnosis because one of the major causes of patients with TRD may be that they indeed have another condition, such as bipolar disorder [27]. While discussions about causes of TRD and advice on which steps to take when dealing with a patient with TRD are certainly informative [26],[27], some fundamental factors need to be addressed. By defining TRD as nonresponse to two adequate courses of treatment, we stop questioning whether the patient may have a subtype of depression for which the benefit of treatments has not yet been demonstrated. The root of the problem stems from the idiosyncrasies of research that clinical trials examining the efficacy of antidepressants have generally recruited depressed patients with symptom profiles that do not fully reflect the heterogeneity of real-world presentations. But healthcare providers assume that the treatment effects seen in these relatively homogeneous populations are generalizable to all depressive presentations in real-world settings. On the contrary, studies such as STAR*D revealed that, in real-world settings, currently available treatments are not as effective as seen in clinical trials [28], and most research findings to date only suggested that antidepressants are effective for a relatively homogeneous subset of depression.

It is thus imperative that, in the future, efficacy studies are conducted on depression subpopulations based on specific phenotypes or even genotypes to more precisely evaluate the conditions under which medications and therapeutic interventions are effective. For instance, patients with depression characterized by excessive sleep, lack of energy, and lack of interest in usual activities are likely to respond differently to treatment with those depressed patients with predominant presentations of feelings of hopelessness, excessive guilt, and suicidal ideation. With the advent of modern technologies, research can continue to test the biological validity of diagnoses and to examine whether subgroups of patients differ in neurocircuitry, genetic profiles, and other biomarkers. Only through continuing efforts to validate accurate diagnosis as well as to develop novel therapeutics for specific subpopulations of patients that are nonresponsive to currently available treatments, we cannot increase potentially risky treatments out of good intention that eventually may have harmful impacts on patients.

  Conclusion Top

To defeat depression, we do not always need to fight more aggressively, instead we may need to step back and alter our approach a little bit – to develop a more accurate diagnostic system, which is hopefully adapted to different cultures, to reconcile the difference in the perceptions of treatment priority and functionality between patients and healthcare providers, which may greatly improve therapeutic alliance and treatment outcome, and last but perhaps foremost, to explore novel therapeutic interventions for subpopulations of patients who may not respond satisfactorily to currently available treatments.

  References Top

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