Diana looked at her pill bottles and wondered why she was on all these medications when she did not feel any better. She looked at the five bottles: bupropion, paroxetine, diazepam, alprazolam, and zolpidem. She thought about the side effects she was experiencing.
She had been taking this cocktail, in various dosages, for the best part of a year now. Her depression remained unchanged. She made a decision that she would tell her psychiatrist that she wanted off the medications at her next visit. She would then ask for other treatments. She had found many therapies offered on the Internet for treatment of depression, and she hoped her psychiatrist would be able to help her decide which therapies might be best suited for her. Perhaps she would agree to stay on one medication as a compromise as she knew her psychiatrist thought treatment of depression with medication to be important.
Up to 30% of patients with depression do not respond to multiple treatment trials and are considered to have treatment-resistant depression. Most treatment trials for these patients focus on symptom reduction as a goal. This emphasis on symptom reduction often leads to tunnel vision, where other evidence-based treatments become marginalized by psychiatrists. Thus, patients like Diana end up on multiple medications, without an integrated approach to assessment or discussion of combined treatments (medications and psychotherapy).
Dr. Gabor Keitner, who practices in Providence, R.I., and is a member of the Association of Family Psychiatrists, offers a new program aimed at helping patients manage their depression. His philosophical stance is that depression is a chronic illness and that expecting symptoms to be cured with medications is, for most patients, a false hope perpetuated by a consumer society, where the pharmaceutical industry has dominated the education of patients, their families, and the psychiatric profession. He conceptualizes depression, like other chronic medical illnesses, such as diabetes or hypertension, with a similar range of severity. Therefore, the assessment and treatment of depression requires a more nuanced approach.
He is scheduled to present his Management of Depression (MOD) program at this year’s American Psychiatric Association meeting in San Francisco. His MOD program focuses on how a patient such as Diana can build a satisfying life with meaningful goals and relationships – even if her depressive symptoms persist.
In his pilot study, 30 patients with treatment-resistant depression were randomized to treatment as usual (TAU, n = 13) or the MOD program (n = 17) for 12 weeks. The patients in the MOD group had significant improvement in perception of social support (P < .034) and purpose in life (P < .038) scores, in contrast to the TAU group. The MOD group participated in nine adjunctive sessions of disease management focused therapy. The Scales of Psychological Well-Being measured purpose in life, life goals, and meaning. Social support was measured with the Multidimensional Scale of Perceived Social Support. Depression severity was measured by the Montgomery-Åsberg Depression Rating Scale. Patients were assessed at baseline and week 12. Both groups of patients had significant improvements in their depressive symptoms (TAU 35.46 to 25.9 P < .010; MOD 31.88 to 22.41 P < .001) but continued to experience moderate levels of depression. Adjunctive treatment focusing on functioning, life meaning, and relationships, as opposed to symptom reduction, will help Diana to have a more satisfying life, despite her symptoms of depression.
Measuring relational functioning briefly
In another session, Dr. Keitner is slated to present "The Brief Multidimensional Assessment Scale (BMAS): A Mental Health Check Up," coauthored with Abigail K. Mansfield Maraccio, Ph.D., and Joan Kelley. This scale evaluates global mental health outcomes, including quality of life, symptoms, functioning, and relationships. This measure can be used to assess the clinical status of patients at every health encounter and over the course of an illness. Most available scales are either too long for routine clinical use, focus on a narrow range of symptoms, or focus on specific diagnostic groups. Best of all, this new scale takes less than a minute to complete.
The BMAS was tested against The Outcome Questionnaire–45 (OQ45) with 248 psychiatric outpatients as part of their standard ongoing care. Internal consistency was evaluated with Cronbach’s alpha, which was .75 for the four items. Test-retest reliability was assessed using Pearson’s r and ranged from .45 (symptom severity, which can fluctuate daily) to .79 (quality of life) for each of the BMAS items. Concurrent and convergent validity was analyzed with Pearson product moment correlations between BMAS and OQ45 scales. All correlations were significant for the relevant dimensions.